To describe the technique of transurethral harvesting of bladder mucosal graft using the Holmium:YAG (Ho-YAG) laser and describe the preliminary results from 7 cases where this graft was used for urethroplasty.We performed a single-stage dorsal onlay urethroplasty using bladder mucosal graft in 7 patients with anterior urethral stricture. Transurethral harvesting was performed with the Ho-YAG laser. We performed a prospective and descriptive analysis with uroflowmetry performed at 30, 90 and 180 days after surgery and applied the PROM translated into Portuguese before and 6 months after urethroplasty.Seven patients were included, 2 (28.5%) with penile urethral stricture, and 5 (71.5%) with bulbar urethral stricture. Mean stricture length was 50mm (range 35-60mm). Stricture etiology was trauma in 3 (42.9%) patients, iatrogenic in 1 (14.3%) patient, and idiopathic in 3 (42.9%) patients. Two patients (28.6%) had previously undergone ventral buccal mucosa urethroplasty. Mean bladder mucosal graft length was 52.86mm (± 13.801), and mean harvest time was 46.43min (± 14.639). Dorsal onlay urethroplasty using bladder mucosa was successfully completed in 5 patients (71.4%). Two patients (28.6%) couldn't have the procedure completed using bladder mucosa, one due to thermal damage of the graft during harvesting, and one due to insufficient graft length. In both cases the procedure was completed using buccal mucosa. Two patients (28.6%) experienced minor hematuria between the twelfth and eighteenth postoperative day, but neither required hospitalization and/or additional procedures. All patients achieved normalization of peak flow, and this was maintained throughout the follow-up period. Mean peak flow was 17.8 ml/s (± 3.271) at 30 days, 20.6 ml/s (± 5.413) at 90 days, and 19.6 ml/s (± 8.019) 180 days. Mean IPSS score decreased from 19.3 to 5.4. Similar improvements were also seen in the ICIQ-MLUTS Score (a mean drop from 3.8 to 2.0) and Peeling's Voiding Picture Score (a mean drop from 4.0 to 2.2). Quality of Life improved post urethroplasty, with increases in EQ-5D (from 0.6371 to 0.7285) and EQ-VAS (from 58.0 to 84.0).Transurethral harvesting of bladder mucosa using the Holmium laser (Ho-YAG) is feasible and reproducible. Our preliminary experience suggests that bladder mucosa grafts achieve comparable results to other grafts when used for dorsal onlay urethroplasty. Further research is needed to confirm these results. Urethral stricture disease is defined as a partial or total obliteration of the urethral lumen. In the United States, the estimated prevalence is 0.9% in adult men . Most caReplacement urethroplasty involves harvesting of a graft having suitable characteristics and then implanting it into the recipient site for reconstruction of the narrowed urethra. These grafts can be harvested from various sites being either skin or mucosal tissues. Skin graft locations include genital tissues, including preputial skin, penile shaft skin, and scrotal skin. Grafts can also be harvested from mucosal tissues derived from a variety of locations such as: oral mucosa, lingual mucosa, bladder mucosa, and colonic mucosa . Oral muThe ideal graft for urethral reconstruction should be resilient and able to withstand the humid environment, be easily accessible, hairless, and angled allowing for neovascularization . AlthougBladder mucosa for graft purposes in the treatment of urethral pathologies was first described by Joseph Memmelaar, in 1947 –10.In 2018, Wang Z et al. described transurethral harvesting of bladder mucosa graft in 2 patients using the Hybrid Knife system, which uses a jet of water to aid the process. Short-term follow-up did not reveal any bladder complications .The Holmium laser (Ho-YAG) is a pulsed solid-state laser with a wavelength of 2140 nm and penetration depth of 0.4 mm . Each puOur hypotheses were that Ho-YAG could be used for transurethral harvesting of bladder mucosa, and that this graft would achieve comparable results to more commonly used grafts in dorsal onlay urethroplasty. The primary objective of this article is to describe the technique for transurethral harvesting of a bladder mucosal graft using Ho-YAG laser. The secondary objective is to describe the preliminary results of a series of 7 cases using these grafts to perform substitutive urethroplasties.This study received institutional review board approval (IRB number 51456521.8.0000.5259) and was performed in accordance with the hospital's institutional committee's ethical standards for human experimentation.We prospectively analyzed 7 patients, admitted to our service between November 2021 and January 2023. Inclusion criteria consisted of patients having a diagnosis of anterior urethral stenosis, with or without recurrence, and were indicated for urethroplasty with graft (stenoses greater than 2.5cm). Exclusion criteria included: genitourinary malformations, a history of pelvic radiotherapy, a history of bladder cancer, and those with an indication for staged urethroplasty. Every patient was staged using cystourethrography and uroflowmetry except in those using a suprapubic urinary diversion. The PROMS questionnaire  translatResectoscope 22 or 18.5F;Working element adapted for laser550μm laser fiber;High power Ho-YAG laser (minimum 60W)All surgeries were performed by a single surgeon experienced in urethral surgery. Due to the physical characteristics of the bladder mucosa (soft and tenacious tissue), we chose to perform dorsal onlay  or dorsuAfter placing the patient in the lithotomy position, a perineal incision was made permitting access to the bulbar urethra . The nexA 22 or 18.5F resectoscope with a working element adapted for the laser fiber was then passed through the proximal urethrostomy  followedThe Holmium Laser settings for energy were 0.5 to 0.8J and frequency of 30 to 40 Hz. After filling the bladder to full capacity, a rectangular marking of the donor graft area was made immediately above the Interureteric bar; its lower and upper sides represented by segments AB and DC, respectively, and its lateral sides represented by segments AD and BC .Dissection of the graft was then performed using the 550 μm laser fiber, always going from lateral to medial (AD and BC) and subsequently from proximal to distal (AB to DC), being the deepest plane the muscular layer of the bladder. Meanwhile, the bladder was kept fully distended . Upon coGraft preparation was done by removing any detrusor muscle fragments adhered to the mucosa. Dorsal and/or dorsolateral fixation of the graft to the corpora cavernosa was performed using a 5-0 PDS suture . The graPatients were hospitalized for 48 hours and then discharged with both urinary catheters in place. The urethral Foley catheter was removed in 21 days. A week later, the patient was submitted to uroflowmetry. If the maximum flow was equal to or greater than 14mL/s, the suprapubic urinary diversion was removed. At the intervals of 30-, 90- and 180-days post-operatory, repeated uroflowmetry was performed. After the time of the final evaluation, the PROMS questionnaire translated into Portuguese was reapplied.Therapeutic success was defined as not requiring further procedures, Qmax above 12mL/s, post-void residual below 50mL, and the ability to insert a 15F flexible cystoscope if undergoing diagnostic cystoscopy.Summary statistics are presented as percentages or mean ± SD, as appropriated.Patient characteristics are listed in The mean length of the harvested bladder mucosa graft was 52.86mm (± 13.801) and the time spent for its removal was 46.43min (± 14.64). Five patients (71.4%) had no perioperative complications and/or technical difficulties and went on to have their surgeries completed. However, in 2 patients (28.6%) problems occurred related to the graft extraction. In the first case, the bladder mucosa was burned by the laser, and, in the second situation, the graft was insufficient to complete the procedure. In both cases, the procedure was completed using oral mucosa and these patients were then excluded from the study. Two patients (28.6%) had minor hematuria between the twelfth and eighteenth postoperative day, although both did not need hospitalization and/or additional procedures.All patients achieved the normalization of uroflowmetry (mL/s), sustained throughout the follow-up which occurred at post-operative intervals of 30-days (17.8 ± 3.271), 90-days (20.6 ± 5.413) and 180-days (19.6 ± 8.019) .There was an important improvement in the LUTS Score, with average scores dropping from 19.3 to 5.4. Similar improvements were also seen in the ICIQ-MLUTS Score (mean drop from 3.8 to 2.0) and Peeling Picture Score (mean drop from 4.0 to 2.2). In the variables related to an improvement in the quality of life, there was a mean increase from 0.6371 to 0.7285 in the EQ-5D and from 58.0 to 84.0 in the EQ-VAS, indicating a definite improvement in the quality-of-life following urethroplasty.The use of bladder mucosa for the treatment of complex urethral strictures was described for the first time by Memmelaar et al. in 1947  is an equipment that is easily available and widely used in urological procedures.The first publication on the use of the Ho-YAG for the removal of bladder mucosa with the treatment of urethral stenosis was described by Figueiredo et al  in 2022.It was demonstrated, in our small series study, the possibility of harvesting a graft from bladder mucosa in a safe manner without any type of perioperative complications. Although hematuria did occur during the postoperative period in 2 patients, these were minor episodes, both without the need for hospitalization and/or additional procedures.The mean harvesting time was relatively long (46.43 ± 14.64 minutes), which can be explained by the learning curve the technique required. Furthermore, 2 patients were excluded from our study due to problems related to the harvesting. In the first case, the dissection plane with the laser was very superficial, causing burns and retraction of the bladder mucosa. In the second case, the graft collected was insufficient in size to correct the stenosis. Both cases demonstrate the importance of adequate training so that harvesting is performed on the correct dissection plane. As already evidenced by previous authors , consideExclusion criteria of patients included those presenting genitourinary malformations, a history of pelvic radiotherapy, a history of bladder cancer, and those having an indication for staged urethroplasty. It was decided to exclude genitourinary malformations because, in the past, the vast majority of studies used the bladder mucosa for the correction of multi-operated hypospadias, which has been shown to be a challenging surgery for any graft type.According to past understanding, bladder mucosa does not behave well in dry environments, suffering columnar metaplasia that ends up producing increased viscosity and redundancy21. It was therefore decided to exclude patients with indication for staged urethroplasty and also those with the stricture of the glans urethra, in order to prevent meatal problems.Bladder mucosal grafts are tenacious, soft, and tear easily. Due to these qualities, it was decided to perform urethroplasty techniques that use the corpora cavernosa as a bed to avoid the formation of diverticula, and to facilitate the fixation of the graft within its recipient bed.Despite this study showing limitations inherent to the low number of patients and having a short follow-up, we could observe a consistent improvement in the uroflowmetric parameters and also in all domains of the PROM questionnaire applied both preoperatively and 6 months post-operatively.Transurethral harvesting of bladder mucosa using the Holmium laser (Ho-YAG) is feasible and reproducible. Training is needed to avoid damaging the graft and obtain an appropriately sized graft. Our preliminary experience suggests that bladder mucosa grafts achieve comparable results to other grafts when used for dorsal onlay urethroplasty.Further research is needed to confirm these results.


Coronary events and disease recurrence following coronary artery bypass (CABG) surgery could derive from either failure in the internal thoracic artery (ITA) graft, failure in other conduits or progressive disease in the coronaries. We aim to estimate the contribution of ITA graft failure to the recurrence of symptoms after CABG surgery.Within the Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies registry, we identified patients who had coronary artery bypass grafting from 1997 to 2020 with a single-vessel ITA graft bypass. Deaths, postoperative incidence of coronary angiography and the presence of a failed graft at the time of the angiography were recorded.The study population consisted of 1939 patients with a mean follow-up time (SD) of 17.2 (5.6) years. The cumulative incidence (95% CI) at 20 years for a first clinically-driven postoperative angiography was 38.6% (36.2–41.1). A failed ITA graft was reported in 16.4% of the angiographies.A substantial part of recurrent symptoms of coronary artery disease do not seem to be related to ITA failure. Disease progression in the native coronary vessels may instead be the main driver of symptom recurrence. The left internal thoracic artery (ITA) is regularly used for left anterior descending artery (LAD) grafting as it has demonstrated a better patency and confers a survival benefit compared to saphenous vein grafts (SVGs) . FailureWe evaluate long-term outcomes in a large population of almost 2 000 patients operated with CABG with a single distal anastomosis using ITA as graft, in an observational study. By studying patients with a single coronary anastomosis, the relation between ITA graft failure and recurrence of angina symptoms can be more accurately assessed than in patients who received several grafts due to multiple-vessel disease. We aim to quantify the mortality, incidence of first angiography and evaluate the reported patency of the ITA graft in order to assess the significance of ITA graft failure for the long-term outcome.The study was approved by the Ethical Review Board of the Swedish Ethical Review Authority, Gothenburg, Sweden (Registration number 2020-06252). The Swedish personal identity number allows nationwide registries with the possibility of long-term follow-up. The Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) registry  providesDate of death was obtained from the national population registry. The dates for CABG procedures and postoperative angiographies were available in SWEDEHEART. For each angiography the indication for the procedure and the presence of any significantly stenosed or occluded grafts is registered by the angiographer. The elapsed time from the operation to death and first angiography as well as the presence of a failed graft was used as endpoints. These outcomes represent robust, easily definable, clinically relevant events that are likely to have a high correlation with CAD symptoms and have been used previously to evaluate results after CABG .Patient characteristics were described by using frequencies and percentages for categorical variables, and means and standard deviations for continuous variables. Outcome measures were evaluated in the population as the time from operation to death from any cause and time to first postoperative coronary angiography. Patients were followed from the date of surgery until the date of death from any cause or the end of follow-up .The Kaplan–Meier method was used to illustrate cumulative survival and cumulative incidence of first postoperative angiography. Hazard functions were estimated for the risk of angiography and the risk of finding a failed ITA graft. Indications for the first angiography as well as the presence of failed grafts were described by using frequencies and percentages. Data management and statistical analyses were performed with the use of R version 3.1.3 .In total, 1939 patients operated with CABG with a single distal anastomosis using the ITA as graft between 1997 and 2020 met all inclusion criteria. The mean follow-up time (SD) was 17.2 (5.6) years. Baseline characteristics for the study population are shown in Table Thirty-day mortality was 1.1% (22). Mortality occurred in 44.6% (865) of patients. Survival (95% CI) at 20 years was 47.2% (44.5–49.9)  of patients. The cumulative incidence (95% CI) at 20 years for the first clinically-driven postoperative angiography was 38.6% (36.2–41.1)  of the angiographies, and in 10.9% (73) of cases graft status was unknown. For procedures performed within six months of CABG surgery 20.0% (13) reported graft failure and in 32.3% (21) of patients graft status was unknown (Table We present a large cohort of individuals operated with single vessel coronary bypass using the ITA as graft and report the probability of finding a failed graft found during clinically-driven angiography. The over-all survival was similar to the expected mortality of a matched cohort from the general population. The cumulative incidence of post-operative angiography was approaching 39% 20 years after surgery. The ITA graft was classified as significantly stenosed or occluded in 18% of examined patients with available information regarding graft status. Consequently, about 7% of all operated patients experienced a post-operative angiography within 20 years after surgery, where a failed ITA graft is found. The number of symptomatic failures is, however, probably considerably lower, as asymptomatic ITA failures have been reported to range between 5 and 15% .Predictors of ITA graft failure found during early protocol angiography have been identified as target vessel stenosis of less than 75%, additional bypass graft to diagonal branch, and not having diabetes mellitus . AlthougFor the large majority of patients in this study, recurrent symptoms appear completely unrelated to graft failure, highlighting the significance of atherosclerotic progression in the coronary arteries and the importance of optimal secondary prevention. If similar results could be found also in the setting of multi-vessel CABG it might provide one possible explanation why it has been difficult to demonstrate an improvement in clinical outcome in patients operated with multiple arterial grafts .For single vessel disease, CABG is rarely performed if PCI is an available option. Although the ITA graft probably remains the most reliable alternative, the study does not inform on the choice of treatment in general. The study is limited by the availability, quality and completeness of the registry data. The only patients that are believed to have been lost to follow-up are individuals undergoing coronary angiography outside of Sweden. It is not possible to identify if the right or left ITA was used. There was no formal definition of an occluded or significantly stenosed graft, and it was completely operator dependent. The degree of obstruction of the target vessels is also unknown. Some of the early postoperative angiographies may have been part of a planned hybrid procedure of multi-vessel disease or due to an inability to find or to graft a target vessel during surgery, explaining the high proportion of angiographies performed early after surgery where the ITA graft was not investigated. The majority of the patients in the study had their procedure in the first 5–10 years of the study period, when anti-platelet therapy was not as protocoled as it is now.The current study precisely demonstrates the performance of ITA-LAD in a real world setting and delineates the performance of the optimal CABG graft. The study removes the uncertainties normally associated with the interpretation of results of CABG outcomes due to the presence of multiple conduits. The results underline that symptomatic ITA failure is relatively uncommon on a population level and that disease progression in the native coronary vessels instead could be the dominating driver of symptom recurrence. Likely, more focus should be given to improved secondary prevention and better long-term medical treatment of CABG patients.


This letter summarizes the current situation with a brief literature review and provides an extended discussion referring to past publications on this issue.In biomedical studies, relative measures  are often used to evaluate associations between exposures and outcomes with graphical presentation. Although cautious points for graphical presentation of these indicators have been discussed,American Journal of Epidemiology, the European Journal of Epidemiology, the International Journal of Epidemiology, and the Journal of Epidemiology (Table 2 This problem is prone to mislead not only academic readers but also the general public, who are not familiar with the interpretation of these indices. Therefore, we need to carefully display these types of results in figures.We reviewed the original articles published in the following four epidemiological journals between April 2022 and March 2023: the gy Table . A total1,3 Figure 2,4 This improvement is not substantial compared with previous issues, but it could facilitate a better discussion based on confidence intervals rather than a discussion focusing on only point estimates and P-values. This graphical presentation using points and error bars has commonly appeared in figures for meta-analysis.To improve the clarity of figures, this letter revisits past discussions once again and explains the process and rationale for appropriate visualization. Here, Figure https://github.com/fujichaaan/je_point_estimates_rm.For clear and precise data visualization of point estimates for relative measures, it is preferable to draw them as point + error bars with a logarithmic scale or transparent bar chart + error bars starting from 1 with a logarithmic scale. Researchers need to pay attention to this issue not only in papers and conference presentations but also in dissemination to the public. As a final note, remember that there is a trade-off between visualizing the results in figures and showing them as tables; in other words, it is often impossible to correctly reproduce numerical results from figures. The R codes of data visualization in relative measures for more practical examples are available at


This study aimed to simulate blood flow stagnation using computational fluid dynamics and to clarify the optimal design of segmental artery reattachment for thoracoabdominal aortic repair.Blood flow stagnation, defined by low-velocity volume or area of the segmental artery, was simulated by a 3-dimensional model emulating the systolic phase. Four groups were evaluated: direct anastomosis, graft interposition, loop-graft, and end graft. Based on contemporary clinical studies, direct anastomosis can provide a superior patency rate than other reattachment methods. We hypothesized that stagnation of the blood flow is negatively associated with patency rates. Over time, velocity changes were evaluated.The direct anastomosis method led to the least blood flow stagnation, whilst the end-graft reattachment method resulted in worse blood flow stagnation. The loop-graft method was comparatively during late systole, which was also influenced by configuration of the side branch. Graft interposition using 20 mm showed a low-velocity area in the distal part of the side graft. When comparing length and diameter of an interposed graft, shorter and smaller branches resulted in less blood flow stagnation.In our simulation, direct anastomosis of the segmental artery resulted in the most efficient design in terms of blood flow stagnation. A shorter (<20 mm) and smaller (<10 mm) branch should be used for graft interposition. Loop-graft is an attractive alternative to direct anastomosis; however, its blood flow pattern can be influenced.  Computational fluid dynamics can simulate blood flow stagnation, which is a promising indicator to evaluate optimal design of segmental artery reattachment.The model-based development approach using computational fluid dynamics can be applicable to pursuing superior method of segmental artery reattachment. Simulation of blood flow stagnation is consistent with current clinical outcomes and explains the paucity of patency rates of each design. The computational fluid dynamics model can be a valuable component of future preoperative assessments.,,Spinal cord injury (SCI) remains among the most serious complications of thoracoabdominal aortic aneurysm (TAAA) intervention, with paraplegia occurring at a rate of 2.9% to 16.0%, even in experienced centers.Model-based development (MBD) is a method of evaluating product performance through simulation and optimization by representing the entire product on a functional basis before creating a 3-dimensional (3D) model in the early stages of the product design process in the automotive and aerospace industries.We hypothesize that the blood flow stagnation of a reattached segmental artery influences the patency rate as an objective parameter. The aim of this study was to simulate blood flow stagnation to elucidate the optimal design of reattached segmental arteries for TAAA repair using a CFD model.,A 3D CFD model of segmental artery reattachment was developed to reliably evaluate blood flow stagnation. Blood flow stagnation was defined by volume of velocity ≤0.03 m/second simulating the systolic phase (low-velocity volume), which is supposed to increase viscosity of blood.Simcenter STAR-CCM+ 2022.1 , a general-purpose thermal-fluid analysis software, was used for the fluid analysis. This analysis assumed incompressible Newtonian fluid. The finite volume method was used to discretize the continuity equation By using the finite volume method, the 3D aortic model is divided into a grid, and each cell or boundary surface has representative values, including velocity and pressure. This calculation uses polyhedral mesh, which has the advantage of having a larger number of faces, which improves analytical stability and reduces the number of cells, thereby reducing the computational load compared with tetrahedral mesh. The mesh size was set to a maximum of 0.75 mm and a minimum of 0.075 mm to sufficiently resolve the flow in the aortic model and set boundary layers to resolve velocity gradient. In this setup, there are 36 nodes on the same circumference of the aortic model. This number is sufficient to represent a circle of a polyethylene terephthalate graft.3 and viscosity μ = 0.004 Pa-s.The inlet boundary varies the flow rate and the outlet boundary was given a pressure outlet condition of 120 mm Hg as shown in The difference between compressible and incompressible fluids is whether or not a density change occurs. Compressible fluids that are affected by density changes are generally said to start at Mach numbers = 0.3.The speed of sound (Mach = 1) of water, which is very close in physical properties to blood, is about 1500 m/second, and the velocity of blood flow is much lower than that. Therefore, the calculation is performed as incompressible.To simulate a pulsating flow, this calculation was performed with an implicit unsteady analysis, the time step was 1 ms so that the fluid area of the artificial blood vessel, where blood stagnates, has a courant number A. Direct anastomosis resulted in the least low-velocity volume. When compared with direct anastomosis, end graft showed the largest stagnation of blood flow during the entire systolic phase. Loop-graft showed comparatively less blood flow stagnation over time velocity change; however, it fluctuated particularly during the late systole phase. Graft interposition resulted in significant blood stagnation when compared with direct anastomosis; however, it performed better with less blood stagnation than the end graft reattachment model. These results were consistent when adding the segmental arteries of 3 pairs (B). Notably, the low-velocity volume of graft interposition increased compared with single segmental artery reconstruction, whereas direct anastomosis and loop-graft showed similar pattern of low-velocity volume.The low-velocity volume in systole is summarized in  3 pairs , B. NotaA. A large low-velocity area was identified in the end graft reattachment model. Graft interposition showed significant low-velocity area at the distal end of the branched graft. Similar trends were observed in 3 pairs of reattached segmental arteries (B).The low-velocity area at 0.3 seconds of systole is summarized in arteries , B.FigurThe low-velocity area of plane section in the entire systole phase is shown in A). Comparatively, the 10-mm graft resulted in the least low-velocity volume, reflecting the smaller low-velocity area of the periphery of the branch (B). The advantage of the shorter branch length was maintained throughout in the entirety of systole. A hemisphere shaped branch of 15 mm diameter showed less low-velocity volume in comparison to any other length of cylindrical branches. We also compared graft interposition and aorta at different angles, resulting in a decrease in the volume of the slow region when the graft and aorta approached parallel (A and B).When comparing different graft interposition lengths, the 30-mm graft branch showed significant increase of low-velocity volume compared with the 20-mm graft , A. Compe branch , B. The parallel , A and BA). However, the advantage of smaller branch sizes disappeared during late systole. In addition, significant low-velocity areas of the distal of the branch remained even in the graft with a diameter of 6 mm (B).When comparing graft diameter of an interposed graft, the smaller graft showed less low-velocity volume, particularly during the early systolic phase , A. Howe of 6 mm , B.FigurA and B).Although loop-grafts showed comparative low-velocity volume with direct anastomosis, the flow pattern was influenced by varying configurations of the loop-graft (elongated and curved) , A and BThis study demonstrated that a direct anastomosis reattachment model results in the most efficient design to minimize blood flow stagnation. Loop-graft can be a reasonable alternative, although the configuration should be careful not to attenuate its efficiency . For gra,The rationale of segmental artery reattachment and its implication in reducing SCI is an area with current equipoise in the medical literature. Several studies report that sacrifice of intercostal and lumber arteries during TAAA repair is safe on the basis of the acceptable incidence of SCI.,,Although our CFD simulation were not linked to clinical outcomes, the results of low-velocity volume were consistent with current studies describing patency rates of reattached segmental arteries. Direct anastomosis has been reported as having the highest patency rates of any other model of reattached segmental arteries. However, alternative approaches have also been investigated because there are concerns of surgical bleeding and late aneurysm growth.In the case of graft interposition, the segmental artery and graft are in the same direction, which may have changed the flow pattern, decreasing the slow region at the end of the graft as the diameter of the segmental artery increases. The end graft is slow in many areas to begin with, and it is assumed that the flow pattern is sensitive to differences in the diameter of the segmental artery, and as a result, the slow areas are likely to change as well . HoweverThe MBD approach, which has been utilized by the aerospace and automotive industries for decades, has now moved in to the medical industry. MBD uses different devices and methodologies to facilitate a systematic and methodological control design, alleviates the need for experimental system calibration, and allows for system integration and requirements testing early in the development stage. A CFD model using both nonpatient-specific and patient-specific imaging can be applicable to pursuing better design of not only segmental artery reattachment, but also any surgical decision making where applicable. We believe that CFD models can be a valuable component of the preoperative assessment to provide superior surgical outcomes in the future.Although our results are promising, they are not without limitations. First, it was a simulation-based study. Although the results are consistent with recent clinical publications in the literature, clinical data need to be demonstrated. Secondly, our study did not analyze the fragility or elasticity of the aortic wall such as that in a dissected aorta or connective tissue diseases. The indication of direct anastomosis of a segmental artery should be determined in conjunction with other clinical factors. Thirdly, we did not evaluate the influence of remnant aortic tissue due to the equation of the CFD model. In direct anastomosis, island reconstruction and single-cuff technique could not be compared in this study. Fourthly, it is assumed that the segmental artery and its surrounding geometry will change the peripheral vascular resistance and influence the pressure and velocity in the vessel, but this study has not been able to account for this. This is because it is difficult to make precise predictions without capturing the time-series pressure fluctuations in peripheral blood vessels. The results of pressure measurements downstream of intercostal arteries in animal experiments are awaited. Finally, this model did not simulate how collateral networks influenced the thrombosis or patency rates. Patient-specific CFD models and clinical studies assessing the above findings are required.Patient-nonspecific CFD was useful to simulate the optimal design for segmental artery reconstruction for TAAA repair. Simulated blood flow stagnation appears to be a promising predictor of patency. Direct anastomosis of the segmental artery resulted in the most efficient design to avoid blood flow stagnation, whereas an end graft reattachment model showed the worst stagnant blood flow. A shorter and smaller tube graft should be used for graft interposition to improve patency. Otherwise, the loop-graft is an attractive alternative to direct anastomosis; however, it can be influenced by its configuration.The authors reported no conflicts of interest.Journal policy requires editors and reviewers to disclose conflicts of interest to decline handling or reviewing manuscripts for which they have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.The


Annals of Internal Medicine, The BMJ, Journal of the American Medical Association, The Lancet, Nature Medicine, and The New England Journal of Medicine) but also in infectious disease journals [I read with interest the paper by Delardas and Giannos . As the journals . A similjournals .Delardas and Giannos  evaluate


Preventing ischemia‒reperfusion injury (IRI) is a major issue in kidney transplantation, particularly for transplant recipients receiving a kidney from extended criteria donors (ECD). The main consequence of IRI is delayed graft function (DGF). Hypoxia is one of the key factors in IRI, suggesting that the use of an oxygen carrier as an additive to preservation solution may be useful. In the OxyOp trial, we showed that the organs preserved using the oxygen carrier HEMO2life® displayed significantly less DGF. In the OxyOp2 trial, we aim to definitively test and quantify the efficacy of HEMO2life® for organ preservation in a large population of kidney grafts.OxyOp2 is a prospective, multicenter, randomized, comparative, single-blinded, parallel-group study versus standard of care in renal transplantation. After the selection of a suitable donor according to the inclusion/exclusion criteria, both kidneys will be used in the study. Depending on the characteristics of the donor, both kidneys will be preserved either in static cold storage (standard donors) or on machine perfusion (for ECD and deceased-after-cardiac-death donors (DCD)). The kidneys resulting from one donor will be randomized: one to the standard-of-care arm  and the other to the active treatment arm (HEMO2life® on top of routinely used preservation solution). HEMO2life® will be used for ex vivo graft preservation at a dose of 1 g/l preservation solution. The primary outcome is the occurrence of DGF, defined as the need for renal replacement therapy during the first week after transplantation.The use of HEMO2life® in preservation solutions is a novel approach allowing, for the first time, the delivery of oxygen to organs. Improving graft survival by limiting ischemic lesions is a major public-health goal in the field of organ transplantation.NCT04181710. registered on November 29, 2019.ClinicalTrials.gov, ID:  The order of the items has been modified to group similar items . I/R isPreservation solutions are based on the principle of hypothermia, which is to maintain organs in a solution at 4 °C to reduce metabolism. A recent meta-analysis suggested that the three most popular solutions  bring comparable risks of DGF . Preserv2life®, an oxygen carrier developed by the HEMARINA French Company, is a natural extracellular hemoglobin isolated from the marine lugworm Arenicola marina. This biopolymer of high molecular weight  has a high oxygen binding capacity, carrying up to 156 oxygen molecules when saturated (compared to 4 for human adult hemoglobin). It releases oxygen according to a simple gradient and exhibits intrinsic superoxide dismutase-like activity, preventing both the generation of potentially harmful heme-protein-associated free radical species and the release of hemoglobin degradation products [2life® to preservation solutions prevents the progressive decline in the dissolved oxygen concentration available for the graft [2life® has been demonstrated in preclinical studies. In a porcine model of autologous transplantation after 24 h of cold ischemia in several preservation solutions, HEMO2life® significantly improved the recovery of renal function. After 3 months, animals that received kidneys treated with HEMO2life® exhibited better renal function and less interstitial fibrosis, tubular atrophy and inflammation on kidney biopsy [The medical additive HEMOproducts –25. Priohe graft . The effy biopsy , 27. Thiy biopsy .2life® used as an additive to the preservation solution was safe for the kidney graft and the transplant recipients and that the organs preserved using HEMO2life® displayed significantly less DGF [2life® for organ preservation in a large population of kidney grafts.In a previous proof-of-concept study , we showed that HEMOless DGF , 28. In 2life® added to preservation solution in kidney transplantation.The present research focuses on the efficacy of HEMOThe primary objective is:2life® used as an additive to standard organ preservation solution to prevent DGF following renal transplantation.To quantify the efficacy of HEMOThe secondary objective is as follows:2life®)To assess and compare graft and patient survival in the two groups .2life® on the degree and progression of interstitial fibrosis before implantation and in 3-month biopsies.To evaluate the impact of HEMO2life® for the graft and the graft recipient.To assess the safety profile of HEMOOxyOp2 is a prospective, multicenter, randomized, comparative, single-blinded, parallel-group, superiority study versus standard of care in renal transplantation. After the selection of a suitable donor according to the inclusion/exclusion criteria, both kidneys will be studied. Depending on the characteristics of the donor and following the French recommendations for organ preservation (Agence de la Biomédecine), both kidneys will be preserved either in cold storage or on machine perfusion Fig. . BasicalAll French centers performing adult renal transplantation will participate in the study. They will be divided into two groups. Thirteen centers (first-line) will be involved in organ procurement, randomization, administration of the study molecule, transplantation of the allocated kidneys and follow-up of the patients, whereas the other 19 centers (second-line) will only transplant the allocated kidneys and follow up the patients. Any graft pair retrieved in the participating first-line centers is eligible for inclusion.For kidney graft:any pair of kidneys retrieved from an adult donor in one of the first-line participating centers.any pair of kidneys from a deceased donor after brain or cardiac death (DBD or DCD) who was not opposed of the use of its donation to help scientific research .For kidney recipient:male or female renal allograft recipient at least 18 years old.patient who signed an informed consent form.patient receiving one graft from an included pair of kidneys.For kidney graft:graft from a living donor.graft dedicated to multiorgan transplantation or dual kidney transplantation.donor registered in the French National Registry for Refusal of Organ DonationFor patient:age less than 18 years.refusal to participate in the study.By definition, it will be impossible to get informed consent from the donors. However, according to French law, the grafts will be included in the study after we check the French National Registry for Refusal of Organ Donation to see if the deceased subject was not opposed to the use of such donation to help scientific research.2life®.The ethics committee recommended sending a general letter of information about the study to all the patients on the waiting lists of the participating centers. Just before transplantation, the recipients of the graft will be again informed orally by the investigator from the transplant center, and if they accept, they will be asked to sign an informed consent form for the collection of clinical and biological data and conservation of biological samples. A record will be made of which grafts are randomized in the study but grafted to recipients who refuse to give their consent to participate in this research. This file will be fully anonymized and will be limited to collecting information about the grafts, donors, surgical information and incidents for grafts preserved with HEMOAll the biological specimens used in the study were collected in the routine follow-up of the patients.2life® on top of routinely used preservation solution).The two kidneys coming from one donor will be randomly allocated: one to the standard-of-care arm  and the other to the active treatment arm . For machine-perfused grafts, 1 g of HEMO2life® will be added to 1 l machine perfusion solution, and kidney placement on the machine will be performed according to the usual company protocol. In both situations, the kidney will be rinsed just before transplantation with the plain preservation solution (with no HEMO2life®) to flush out any residual molecules of HEMO2life® and until the liquid becomes clear.HEMONot applicable, treatment is administrated ex vivo.Not applicable, treatment is administrated ex vivo.The study does not forbid any treatment. No specific immunosuppressive regimen is imposed by the protocol, and the immunosuppressive strategy is left to the discretion of the renal transplant center. All concomitant medications taken during the study will be documented in the patient records and in the eCRF.There is no anticipated harm and compensation for trial participation.Primary outcome: The primary outcome is the occurrence of DGF, defined as the need for renal replacement therapy during the first week after transplantation.Secondary outcomes: Efficacy and safety secondary outcomes will be collected.Efficacy: for comparison of the two groups and specific subgroups of donors  and recipients :rate of PNF.graft and patient survival at one year.rate of biopsy-proven acute rejection at one year.DGF, assessed with alternative definitions: more than one dialysis session, need for dialysis except for hyperkaliemia or overhydration reason, time to reach a creatinine value of 250 µmol/l, and number of dialysis sessions.renal function ) at Days 7, 14, and 30 and months 3 and 12; areas under the concentration curves (AUCs) of creatinine and eGFR from D0 to D30.protocol biopsy analysis (preimplantation and at month 3) in a subgroup of 100 patients per group: A) comparison of the chronic scores of tubule-interstitial damage according to the Banff classification : tubularquality of life: at 1, 3 and 12 months, using the generic self-administered questionnaire EQ-5D and a specific questionnaire for renal transplant recipients in the French language: the ReTransQol (RTQ) .2life® will be assessed. In particular, all incidents and events of interest occurring during the use of HEMO2life® will be collected, including packaging issues, difficulty of mixing HEMO2life® into the preservation liquid, perfusion issues, machine perfusion issues, macroscopic aspects of the preservation solution containing HEMO2life®, contamination of the conservation solution, macroscopic aspects of the graft before transplantation, and surgical difficulties.The safety profile of the medical device HEMOGrafts and patient safety will be investigated by collecting all AEs during the first month and all serious AEs up to one year. These events will be analyzed by the sponsor safety and biovigilance department.The kidney recipient will be followed from transplantation to 1 year after transplantation. The clinical and laboratory data of patients will be collected at D0, D1, D3, D7, D14, M1, M2, M3 and M12 . The sample size calculation rests on an expected DGF rate of 28% in the control arm and a 15% rate in the HEMO2life® arm. To guarantee 80% power to detect such a difference at this first step, the minimum sample size per group is 180 evaluable grafts. Expecting 20% of nonevaluable inclusions, a total of 450 patients (225 pairs) are needed.This proposed methodology requires first testing global efficacy at a reduced alpha level, chosen here to be 0.03. In the 3 cumulating years 2015 to 2018 the mean rate of DGF in France was 28% according to the data of Agence de la Biomédecine  is achieved. In total, we expect to include approximately 260 donors in the study.Nonevaluable inclusions include discordant pairs according to the type of conservation (cold storage/perfusion machine) as well as nontransplanted grafts.Randomized allocation will be achieved through "Ennov Clinical", a secure server with access to the e-CRF, by the retrieving investigational team. The randomization will be stratified according to the donor type (standard donor/ECD/DCD) and the destiny of the kidney .Use of a validated password website using a secure server will ensure concealment.The surgeon in charge of the organ procurement is responsible for the randomization and the administration of the medical device.2life® results in a red coloration of the preservation solution, so a double-blind study is not possible. This explains why we designed a single-blind study: the graft recipient will not be informed about the allocated arm.The use of HEMOThe surgeon performing the renal transplantation is not blinded so unblinding will not be necessary.2life®, even if they refuse to participate in the study. In this case, only graft, donor and surgical information and AEs will be collected and recorded in a fully anonymized database, as the patients will not have given their informed consent for biological and clinical data collection.The kidney recipient will be followed from transplantation to 1 year after transplantation. All patients will be followed up. For safety reasons, we plan to follow each patient who has received a graft that has been perfused and stored in a preservation solution containing HEMOThe following data will be recorded: demographic data, medical history of the donor and the recipient, transplant surgical procedure and complications, vital signs, treatments given, and laboratory tests. Renal function will be assessed by measuring serum creatinine and eGFR using the MDRD formula  before s2life®, even if they refuse to participate in the study. In this case, only graft, donor and surgical information and AEs will be collected and recorded in a fully anonymized database, as the patients will not have given their informed consent for biological and clinical data collection.For safety reasons, we plan to follow each patient who has received a graft that has been perfused and stored in a preservation solution containing HEMOSigned informed consentCompliance of the study’s protocol and its described proceduresQC of the collected data into the e-CRF: accuracy, missing data, consistency between these data and those of “source” Data will be entered into the web-based electronic Case Report Form (eCRF) (……) under the supervision of the trial site investigators at each participating center. A Clinical Research Assistant (CRA) appointed by the sponsor will be in charge of the study data collection in writing, data recording, data saving and reporting in accordance with the sponsor Standardized Operating Procedures as well as the Good Clinical Practice guidelines and the in force legislation and laws. The investigator and the members of his/her team agree to be available during all the routine and planned Quality Control (QC) visits by the CRA. During these visits, the followings will be audited:The QC people as well as the investigators are subject to professional confidentiality . During the research or at its end, the collected data on the individuals undergoing the trial sent to the sponsor by the investigators  will be anonymized.No specific biological samples were taken for this study. We verified before the start that all the data needed for the analysis were part of the routine blood samples performed in the transplant centers. Additionally, no biological specimens were stored for genetic or molecular analysis.All complete and concordant (according to the type of conservation: cold storage or perfusion machine) randomized pairs fulfilling the inclusion criteria with no exclusion criterion.Preemptive grafts will be excluded2life® will be excluded, provided that HEMO2life® cancellation is not related to graft function.Randomized pairs who do not receive HEMOFull Analysis Population:All randomized grafts fulfilling the inclusion criteria and no exclusion criterion will be included.Preemptive grafts will be excluded2life® will be excluded provided that HEMO2life® cancellation is not related to graft function.Randomized pairs who do not receive HEMOExtended Full Analysis Population (exploratory):All subjects who receive any study treatment (including control) but excluding subjects who drop out prior to receiving any treatment will be included. Preemptive grafts will be included in the safety population.Regarding renal function, only available data will be used in a first step that assumes that death and dialysis will be balanced in the two groups. A sensitivity analysis will then be performed using the last observation carried forward (LOCF) for deceased patients and a fixed value (eGFR = 5) for dialysis patients.2life®) and the types of preservation (either in cold storage or on machine perfusion), we decided to incorporate this information into the confirmatory testing strategy. This implementation will allow the investigator to make inferences on the overall population and/or on a prespecified subgroup (cold storage). The methodology developed by Alosh and Huque [As we expect a quantitative interaction regarding the DGF (primary outcome) between the preservation solution  will be used to perform the primary efficacy analyses. McNemar's test will be used to compare paired proportions (DGF) between patients receiving a kidney preserved with HEMODGF proportions will be compared within the machine perfusion subgroup using McNemar's test for paired data in the FAS, as will qualitative secondary outcomes. Quantitative outcomes will be compared between the two groups using the paired t test, or the paired Wilcoxon test whenever the normality condition required for the t test is not satisfied.Graft survival, death-censored graft survival and patient survival will be described in the 2 groups by Kaplan‒Meier curves. The graft survival analysis treats death as graft failure, whereas the follow-up period is censored at the date of death in the event of death with a functioning graft to calculate death-censored survival. Comparisons will be done using a log-rank test, and a Cox model will allow us to estimate hazard ratios with 95% confidence intervals. A shared frailty model for paired survival data will then be used for exploratory purposes in an attempt to take into account pairing.The time to reach a creatinine value of 250 μmol/l will be analyzed using Kaplan-Meir curves, log-rank tests and Cox models. Two ways of considering patients with primary nonfunction will be used: excluding them from the analysis and assuming that this value is not reached and censoring at the end of the follow-up period.For exploratory purposes, two additional approaches will be taken, allowing us to take into account competitive risks (death or graft loss) and pairing: a cause-specific model  and a regression model of subdistribution hazards for clustered right-censored data , 34.Adverse events will be described using the Preferred Terms (PT) of the MedDRA Hierarchy. The chi-square test or Fisher’s exact test will be used to compare proportions between the two groups.Not applicable, no interim analysis planned.Not applicable, no additional analysis planned.No missing data of the primary outcome are expected except for early (first week) deceased patients. For them, the primary outcome will be imputed as a failure .As French law, the datasets generated and/or analyzed during the current study are not publicly available but are available for scientific purpose from the corresponding author on reasonable request after the agreement of the sponsor and the ethics and steering committees.A steering committee has been formed, composed of the principal investigator of each participating center from the first line. It will be responsible for the smooth conduct of the study. It will discuss needed changes to the protocol and will analyze safety reports and alerts prepared by the sponsor or the Independent Data and Safety Monitoring Board composed of three independent experts (IDSMB).The data will be monitored by an IDSMB of three independent experts in the field of kidney transplantation. The role of the DSMB is to monitor the data from published clinical research that affect patient safety and to ensure that the risk/benefit balance is maintained. Safety reports after the first 25, 75 and 150 pair grafts that have reached the first week after transplantation will be transmitted to the DSMB by the sponsor. This document will be issued within a month by the sponsor safety department and will gather all reported SAEs and AEs, as well as a summary of the incidents/events of interest that occurred during surgeries. A meeting of the IDSMB will be held immediately, and the IDSMB will have to give its recommendation to the steering committee no later than one week after: continuation of study without protocol modification, modification of protocol to improve patient security, and early termination.SPIRIT guidance: Plans for collecting, assessing, reporting, and managing solicited and spontaneously reported adverse events and other unintended effects of trial interventions or trial conduct. All adverse events, even unrelated to HEMO2life® occurring during the first month, serious adverse event occurring during the 12 months after transplantation or adverse effect with no time limit will be collected in the study database. When the investigator evaluates the AE as abiding the definition of serious AE, he/she will declare it to the safety Department of the Brest University Hospital. The sponsor must establish once a year during the duration of the clinical trial or on request, an Annual Security Report (ASR) on the clinical trial concerned. He must send it to Agence Nationale de Sécurité du Médicament (ANSM) and Ethic Committee. Its objective is to describe concisely any new information relevant to the safety and assess the safety of persons participating in this Clinical trial.The trial will be supervised by the sponsor. Research assistants from Brest University Hospital will regularly perform on-site checks of adherence to the protocol and accuracy of the recorded data. Newsletters will be regularly sent to all participants to provide support, information and to recall key instructions. Safety reports after the first 25, 75 and 150 pair grafts will be transmitted to the DSMB by the sponsor. A meeting of the IDSMB will be held immediately, and the IDSMB will have to give its recommendation to the steering committee no later than one week after.The sponsor’s approval is required, in case of any substantial modification applied to the protocol by the investigator. Prior to the trial implementation, the sponsor will be in charge of obtaining the Ethic Committee approval and the regulatory authorization within their respective framework. These modifications will be notified to the participating centers.Communications and scientific reports about the study will be elaborated under the principal investigator’s responsibility after co-investigators’ approval. All actors who have contributed substantially in study design, data collection, data analysis and interpretation, manuscript preparation and critical revising, and in final manuscript version approval, will be affiliated as authors. The sponsor and funders will be acknowledged in the published manuscript. Publishing rules will follow the international recommendations :309–15).2life® in preservation solutions is a novel approach, allowing for the first time the delivery of oxygen to organs in storage. Preclinical studies in different animal models have suggested the perfect safety of the molecule and its beneficial effect on ischemia‒reperfusion phenomena [2life® tolerance in humans was evaluated in our previous safety study [2life®. The opportunity is due to this breakthrough oxygen carrier, HEMO2life®, and its ability to reduce lesions induced by hypoxia is of major interest. Improving graft survival by limiting these lesions is a major goal of public health in the field of organ transplantation. Its use for the preservation of other organs, particularly for those prone to IRI, such as hearts and lungs, is also expected.The use of HEMOhenomena , 25. Clity study , 27. TheDue to the Covid pandemia the inclusions that were supposed to start in February 2020 were delayed and the recruitment was difficult until end of 2020. The uncertainty regarding the recruitment and the risk of withdrawal of the study explain that we did not submit the manuscript before. Finally, we included the last patient in July 2022. A total of 520 patients were finally included to obtain the 160 pairs needed for analysis. The last one-year visit of the last patient is scheduled in July 2023.


Female professional athletes with oral contraceptive (OC) intake showed higher patellar tendon stiffness than athletes without OC intake , but not significantly. Conclusion: In professional athletes, there are no significant differences in patellar tendon stiffness according to gender, age, BMI and type of sport . Oral contraceptives may not have an impact on patellar tendon stiffness in female athletes. Further studies are necessary.Background: Injuries of the patellar tendon commonly occur as a result of mechanical loading of the tendon during physical activity. Shear wave elastography (SWE) is an established technique for assessing tendon stiffness, and has good interindividual reliability. The aim of this study was to investigate the impacts of physical parameters and different sports on patellar tendon stiffness in professional athletes using SWE. Methods: Standardized patellar tendon SWE was performed in a relaxed supine position with a small roll under the knee (20° flexion) in 60 healthy professional athletes . Multiple linear regression was performed for patellar tendon stiffness including gender, age, body mass index (BMI), and type of sport. Results: Patellar tendon stiffness showed no significant difference between female (3.320 m/s) and male (3.416 m/s) professional athletes. Mean age  and BMI (female: 23.24 kg/m Injuries of the patellar tendon (PT) commonly occur as a result of high mechanical loading of the tendon during physical activity. Athletes practicing sports involving jumping like volleyball or basketball have a lifetime risk of developing patellar tendinopathy of 50–55% ,2,3. In Tendons combine elastic and viscous characteristics when undergoing deformation in response to stress—known as viscoelasticity. Changes in this molecular structure have an impact on tendon stiffness and function . If not Furthermore, musculoskeletal tissue expresses sex hormone receptors ,10,11, wLower tendon stiffness may lead to higher tension and stronger deformation due to high force impact. It has also been discussed that mechanical tendon changes may affect muscle response latency, which may be a relevant risk factor for musculoskeletal injuries ,15. The Shear wave elastography (SWE) is a technology used to quantify tendon stiffness, and shows potential in visualizing tendon changes, resulting in an improved diagnosis of tendinopathy , which lProfessional athletes in jumping sports are at high risk for patellar tendinopathy and patellofemoral pain syndrome (PFPS) . PatellaThe prospective study included 60 healthy professional athletes. The inclusion criteria were: (I) healthy professional athletes, (II) without any acute (<6 months) musculoskeletal, rheumatic or vascular comorbidities and no previous injuries of the patellar tendon, especially no PFPS, and (III) written informed consent to participate in the study. The following exclusion criteria were applied: tendon changes such as neovascularization, hypoechogenic areas and tendon thickening. The study was conducted in accordance with the Declaration of Helsinki and with the approval of the local ethics committee of Charité—University Medicine .Baseline characteristics of study participants were acquired by a standardized questionnaire prior to the examination. There was a 30 min rest time due to the questionnaire survey before SWE measurement. On the day of the US-SWE examination, no training was performed. All examinations were jointly performed by a trained sonographer and a highly experienced radiologist who were blinded to the type of sport.US-SWE examinations were performed using a standardized protocol. For assessment of the PT, patients were positioned in a relaxed supine position with a small roll under the knee (resulting in a 20° flexion) . Prior tUS-SWE examinations were performed in longitudinal orientation to depict the tendon and the area of interest in a single image . Using tMultiple linear regression analysis of PT stiffness was performed using anthropometric parameters such as gender, age, BMI, and type of sport as input parameters. Continuous variables were tested for normal distribution using the Kolmogorov–Smirnov test. Not normally distributed variables are reported as median and interquartile range (IQR). A two-sided significance level of α = 0.05 was defined as appropriate to indicate statistical significance. All statistical analyses were performed using the SPSS software .2 (21.90–24.43). No chronic diseases or acute health restrictions in general or of the lower limb joints were known. In particular, no patellar tendon injuries, symptoms of Osgood–Schlatter disease, or PFPS were reported. Nine female athletes took oral contraceptives. All professional athletes trained more than ten hours per week. Different types of sports were included . Seven athletes in the oral contraceptive group (OC) took a combined oral contraceptive (with 0.02 to 0.03 mg ethinylestradiol), while two took a desogestrel preparation (0.075 mg). All athletes in the OC group took oral contraceptives for one year minimum. All athletes in OC and NOC confirmed that they have had a regular menstrual cycle of 28 ± 2 days for at least one year. The first day of the last menses was recorded by questionnaire. The day of examination was then allocated to a day in the menstrual cycle with days 1–7 being allocated to the early follicular phase (menses), days 8–14 being allocated to the late follicular phase and days 15–28 being allocated to the luteal phase, as the luteal phase is known to generally last fourteen days. A total of 60 professional athletes  with a median age of 19.00 years (18.00–23.25) years were examined. The median body mass index (BMI) was 23.02 kg/mp > 0.05). Patellar tendon stiffness was highest in hammer throw athletes (3.61 m/s), followed by sprinters (3.50 m/s), soccer players (3.34 m/s), handball players (3.21 m/s), and volleyball players (3.04 m/s). Analysis of variance (ANOVA) for PT stiffness revealed no significant impacts of gender, age, BMI or type of sport. The results are compiled in In the total study population of 60 professional athletes, mean patellar tendon stiffness was 3.165 m/s. No significant difference was found between female and male professional athletes (p = 0.053). The results are presented in Nine professional female athletes took an oral contraceptive pill. The subgroup analysis revealed higher patellar tendon SWE values in female athletes with oral contraceptive intake, but this was not significant , which is in line with the findings of Esmeili et al. [Furthermore, our results in the total study population have not demonstrated a significant difference between different types of sports . Estrogen fluctuations may influence musculoskeletal tissue and collagen synthesis, and fibroblast proliferation may be reduced in the high-hormone phase of the menstrual cycle [Patellar tendon stiffness in female professional athletes with oral contraceptive intake was higher in comparison to athletes without oral contraceptive intake (OC: 3.723 m/s versus NOC: 3.017 m/s), but it was not significant . Oral contraceptives may not have an impact on patellar tendon stiffness in female athletes. SWE is a reliable modality to detect abnormal tendon stiffness. Regular longitudinal examinations of the patellar tendon in professional athletes might help to detect early stiffness changes, as an early sign of injury. However, a strict examination protocol is necessary to obtain reliable measurements of tendon stiffness. Further research is necessary to elucidate the value of this technique in preventive programs for professional athletes.


Knowing the potential hamstring tendon length is relevant for planning ligament reconstructions in children and adolescents, as it is not uncommon to encounter small hamstring tendons intraoperatively. The aim of this study is to predict semitendinosus and gracilis tendon length based on anthropometric values in children and adolescents. The secondary aim is to analyse hamstring tendon autograft characteristics in a closed socket anterior cruciate ligament reconstructions and to evaluate the relationship with anthropometric variables. The hypothesis of this study was that height is predictor of hamstring tendon length and thereby graft characteristics.This observational study included two cohorts of adolescents undergoing ligament reconstructions between 2007–2014 and 2017–2020. Age, sex, height and weight were recorded preoperatively. Semitendinosus and gracilis tendon length and graft characteristics were measured intraoperatively. Regression analysis was performed on tendon length and anthropometric values. Subgroup analyses of the closed socket ACL reconstruction were performed and the relation between anthropometric values and graft characteristics were analysed.The population consisted of 171 adolescents from 13 to 17 years of age, with a median age of 16 years [IQR 16–17]. The median semitendinosus tendon length was 29 cm [IQR 26–30] and gracilis tendon length was 27 cm [IQR 25–29]. Height was a significant predictor of semitendinosus and gracilis tendon length. Subgroup analysis of the closed socket ACL reconstructions showed that in 75% of the procedure, the semitendinosus tendon alone was sufficient to create a graft with a minimum diameter of 8.0 mm.Height is a significant predictor of semitendinosus and gracilis tendon length in adolescents between 13 and 17 years of age and outcomes are similar to data in adults. In 75% of the closed socket ACL reconstructions, the semitendinosus tendon alone is sufficient to create an adequate graft with a minimum diameter of 8 mm. Additional use of the gracilis tendon is more often necessary in females and shorter patients.3 Anterior cruciate ligament (ACL) injury in children and adolescents is a severe injury of the knee. The ACL reconstruction technique for children and adolescents depends on skeletal maturity and is also surgeon dependent , 2. HoweQuadrupled hamstring autograft is most commonly used as soft tissue graft for ACL reconstruction in children and adolescents . Both seThe primary aim of this study is to analyse the preoperative predictability of the ST and G tendon lengths based on anthropometric data in adolescents. We hypothesize that height will be a relevant anthropometric predictor. As a secondary aim this study analyses anthropometric characteristics in relation with graft characteristics, such as ST or STG graft, length and diameter in a closed socket ACL reconstruction technique. We hypothesize that graft characteristics in a closed socket ACL reconstruction, such as additional use of G tendon for graft (ST versus STG graft), can also be predicted by height due to the predictability of tendon length by height.In this retrospective study of prospectively obtained data, consecutive adolescent patients with ACL rupture, scheduled for ACL reconstruction between 2007–2014 and 2017–2020, were eligible for inclusion. In both periods, preoperative height, weight, BMI, sex and age were recorded and hamstring tendon lengths and graft characteristics were described intra-operatively. In the period from 2014 to 2017, the hamstring tendon lengths were not measured and patients from that period were therefore not included in this study. The patients included between 2007 and 2014 were also part of the data analysed in the study by Janssen et al.  and in tTwo orthopaedic surgeons (RJ and MvdB) performed all procedures using the same technique. From 2007 to 2014, a STG autograft with WasherLoc™  was used as the primary graft for a full-tunnel ACL reconstruction. The methodological description of that period has been published previously , 20.From 2017, a closed socket technique  was used to reconstruct the ACL in young ACL reconstruction patients with the ST as autograft type of choice. The ST tendon was harvested and prepared in a standardized fashion according to the previous study , 20. TheDescriptive analyses were used to describe the groups based on the ACL reconstruction technique. Baseline parameters were compared between groups by medians of the Mann Whitney U test after tests for normality for the continuous variables and Chi square test for sex. Multivariate linear regression analyses were performed to predict the length of harvested ST and G tendons length. As variables of interest the anthropometric parameters sex, age, height, weight and BMI were considered. In order to create a standard 4-ST graft a minimum of 24 cm ST tendon length is necessary, therefore the division between significant anthropometric values and ST tendon length of 24 cm was analysed. Additional analyses were performed on the 2017–2020 closed socket technique subgroup. A logistic regression analysis was performed to analyse the necessity for additional use of the G tendon in the 2017–2020 group. Data analysis was performed in SPSS Statistics version 22.0 . Significance was set at ≤ 0.05 in all analyses.The Institutional Review Board (IRB) of The Medical Ethical Committee Máxima Medisch Centrum determined that this study was not subjected to the guidelines of the Medical Research Involving Human Subjects Acts (WMO) (N20.038).A total of 171 patients were included for analysis, of which 99 patients were included in the period from 2007–2014 and 72 patients from 2017–2020. See Table The multivariate linear regression analyses in the total group on the ST and G tendon lengths are shown in Table In order to create a standard 4-ST graft, the required ST tendon length was 24 cm. In Table In the 2017–2020 group, 75% of the closed socket ACL reconstructions were performed with a ST tendon autograft only. In 18 (25%) cases, an additional G tendon autograft was necessary to achieve adequate graft dimension. Patients with a STG graft were significantly more often female, were shorter and lighter and had shorter ST tendons as is shown in Table Four of the 72 patients (6%) had a graft diameter of less than 8 mm , which were all ST grafts and these graft configurations were accepted intra-operatively. Four strand ST graft was used most frequently. In case of using an STG graft, a six strand variation was used most frequently.The results of the univariate logistic regression analyses of height and additional G tendon use as hamstring autograft is shown in Table p-value < 0.001). Males also were heavier than females . Univariate logistic regression analysis of height and additional G tendon use within females  showed no statistically significant value of height as is shown in Table Patients with an STG graft were significantly more often females. Differences in height and weight could therefore be the result of differences in sex between groups and not to differences in BMI, as BMI was similar in both groups. Males had a significantly greater median height than females (180 cm [IQR 175–185] versus 168 cm [165–170], Height is a significant predictor of ST and G tendon length in the age category of 13 to 17 years. This study is the first study to analyse the relationship between anthropometrics, hamstring tendon lengths and graft characteristics in a closed-socket ACL reconstruction. Knowing the potential ST and G tendon length is relevant for planning the hamstring tendon autograft for ligament reconstructions in adolescents , 12. ComConsidering that adolescents experience a growth spurt it might be surprising that age was not a significant predictor for tendon lengths in the multivariate regression analyses. However, considering the large variation in onset and duration of this growth spurt , maturatCurrent ACL reconstruction techniques allow the use of multiple-stranded hamstring autografts and depending on the reconstruction technique, different socket/tunnel lengths require different graft lengths . For exaIn the current cohort of the closed socket technique, 25% of the reconstructed ACL autografts required an additional G tendon to create a graft of sufficient diameter. All STG grafts had a diameter of more than 8 mm and did not need augmentation of contralateral hamstring tendon autograft or allograft. This finding is somehow similar to the outcomes of the study by Stergios et al. , who fouThis study has several limitations. The first limitation is that the diameter of the tendons is not measured, although most likely both tendon length and diameter contribute to graft size. Recent studies showed that anthropometric data and CSA measurements of hamstring tendon on MRI are correlated to the diameter of hamstring grafts –19, 33. Height is a significant predictor of ST and G tendon length in adolescents between 13 and 17 years of age and outcomes are similar to data in adults. In 75% of the closed socket ACL reconstructions, the ST tendon alone is sufficient to create an adequate graft with a minimum diameter of 8 mm. Additional use of the G tendon is more often necessary in females and shorter patients.


Hamstring tendons are a very commonly used autograft for anterior cruciate ligament (ACL) reconstruction. Given that larger hamstring graft diameter has been shown to positively affect outcomes after ACL reconstruction, several techniques have been developed to optimize this variable. In this technical note, we describe the operative technique for generation of a 5-strand hamstring autograft via tripling of the semitendinosus tendon and doubling of the gracilis tendon, which can serve to maximize graft diameter, especially in patient populations with undersized hamstring tendons at baseline. Tripled hamstring tendon autograft consists of a double portion of the tendon with another strand, the central strand, tied to the loop of a suspensory device. This technique is performed to increase the graft diameter. The muscle tissue is first sharply debrided from each tendon. Each graft measured 27 cm in length. Each end of the tendon that was not previously sutured is sutured using FiberWire to Krakow stitch beginning distally to proximally, and then proximally to distally on the opposite side of the tendon. Both tendons were wrapped in half to first estimate size with tubular sizes. In this case, the double-tendon graft easily fit through the size 8 cylinder, so the decision was made to triple the tendon to increase the graft size. The distal end of of the semitendinosus tendon was secured to the adjustable loop fixation device with a surgical knot consisting of 4 square knots. The free ends of the sutures were then cut at the knot. One-third of the tendon was passed through the suspensory loop fixation device, tripling the graft. A luggage tag stitch was placed through the folded end to facilitate graft holding. At this point, we have our tripled graft. We attach the graft to the jig, so we can tubularize the graft. This is done with a Krakow stitch using FiberWire that goes through all 3 tendons and is finished by tying the ends with 4 square knots. Our graft is now tripled. The nontripled gracilis tendon is now passed through and wrapped in half through the suspensory loop fixation device over the completed semitendinosus tendon. With this technique, the graft is routinely 9 mm in size. Hamstring autografts are frequently used in anterior cruciate ligament reconstruction (ACLR). Numerous technical factors have been theorized to affect outcomes in ACLR, from graft size and length to tunnel positioning.4,Given this established risk factor for ACLR failure, there has been increased interest in the development of techniques that optimize graft diameter. One such technique, which consists of tripling the semitendinosus tendon and doubling the gracilis tendon to create a 5-strand graft, has gained considerable traction in recent years, as it can allow for utilization of the hamstring graft, even in patients whose hamstring tendons are naturally undersized.In this technical note, we present the technique of generating a 5-strand hamstring tendon graft secured through an Ultrabutton adjustable loop fixation device  for use in ACL reconstruction.After anesthetic induction, an examination under anesthesia is performed, and the patient is placed supine on the operating table with the knee prepared and draped in the usual sterile fashion. Bony landmarks are identified, and standard anteromedial and anterolateral portals are marked. In addition, for hamstring harvest, an oblique incision is marked 2 finger-breaths below the joint line along the medial edge of the patella .Fig 1PosFor hamstring harvest, an incision is made with a scalpel, and a sharp dissection is carried down to sartorial fascia. After incising fascia, the semitendinosus and gracilis tendons are identified via palpation. After incision of the superior margins of the tendons, each tendon is isolated with a Penrose drain . A closeFor graft preparation, the tendon is first sharply debrided of all muscle tissue with scalpel . The endAfter ensuring that the graft fits snugly through the size 8 cylinder, attention is then given to the knee, where a standard diagnostic knee scope is performed. Afterward, the ACL footprint is debrided from the trochlear notch with a shaver, taking care to note the origin and insertion of the anatomic ACL. The center of the femoral footprint is marked 6 mm anterior to the posterior cortex of the femur with the knee flexed to 90°. Utilizing an inside-out technique, the knee is hyper-flexed to 120°, a guide pin is placed through the eventual femoral tunnel site and driven out the lateral leg, and then over-reamed to create the femoral tunnel. The tibial tunnel drill guide is then placed through the anteromedial portal at the posterior aspect of the anterior horn of the lateral meniscus and the tibial tunnel is drilled arthroscopically. Although viewing from the medial portal, the fixation device sutures holding the graft are first passed through the tibial tunnel and then the femoral tunnel. Then the graft is pulled through using leading suture strands. Once the suture button is passed through the femur, the button-flipping sutures are pulled to ensure the button has flipped and sits flush with the femur. Afterward, the white suture is pulled to reduce and tension the graft following by the placement of the intra-fix implant to secure the graft on the tibial side.3. In the same study, the authors found that the mean graft size for all patients was 7.9 mm, with female patients having a mean diameter of 7.7 mm. Therefore, the data illustrate that undersized hamstring autografts are a relatively common occurrence and more likely to lead to worse outcomes.,,,Hamstring graft size diameter has become an increasing point of emphasis in ensuring positive ACLR outcomes in recent years. In a prospective study of 257 patients who had undergone ACLR, Magnussen et al. founded that revision was performed in 1.7% of patients with graft greater than 8 mm in diameter, compared to 6.5% in those with 7.5-8-mm grafts, and 13.6% in grafts less than 7 mmIn this technical note, we present the technique for generating a 5-strand hamstring graft through tripling of the semitendinosus tendon and doubling of the gracilis tendon. Although this technique does increase graft diameter, it sacrifices graft length in order to do so. Although this could theoretically compromise graft incorporation within the tunnels, recent studies have indicated that graft length is not as predictive of outcomes as previously thought .11, 12, This technique allows for optimization of ACL autograft diameter, which can positively affect postoperative outcomes, as well as expand the patient population in which surgeons can utilize hamstring autografts.


Correction to: Clinical Rheumatology10.1007/s10067-023-06670-0The Figs.


Chinese steamed breads (CSBs) are long-established staple foods in China. To enhance the nutritional value, coarse cereals such as oats, buckwheat, and quinoa have been added to the formulation for making CSBs. This review presents the nutritional value of various coarse cereals and analyses the interactions between the functional components of coarse cereals in the dough. The addition of coarse cereals leads to changes in the rheological, fermentation, and pasting aging properties of the dough, which further deteriorates the appearance and texture of CSBs. This review can provide some suggestions and guidelines for the production of staple and nutritious staple foods. Chinese steamed breads (CSBs) are traditional staple food in north China, also called “mantou.” CSBs are great energy supplement because of their simple recipe and easy availability of ingredients. The food industry has evolved over thousands of years, CSBs are still one of the most critical foods in China . RecentlAs consumers’ dietary concepts gradually move toward low sugar and rich nutrition, traditional CSBs are increasingly considered not a portion of healthy food. It has a high glycemic index, which is not friendly to diabetics and consumers who need to lose weight . ConsideCoarse cereals have a variety of definitions in relevant studies. Some researchers believe that grain crops other than rice and wheat are counted as coarse cereals, such as corn, oats, sorghum, etc. . Some reIn this review, the nutritional components of coarse cereals were statistically analyzed, followed by the effect of the addition of various coarse cereals to wheat flour on the rheological, fermentation, and pasting characteristics of the dough, as well as the appearance and textural characteristics of the corresponding coarse cereals CSBs. Following these conclusions, the article discusses the trends and directions of the relevant industries.As shown in the Besides, many kinds of cereal contain higher levels of phytochemicals than wheat, especially polyphenols . PolypheIn addition, most coarse cereals contain higher dietary fiber content , which cWhen coarse cereals and wheat flour are used to make CSBs, not only the nutritional value of steamed bread changed, but also many changes can be observed in the process of making CSBs. These interrelated changes are reflected in dough morphology, rheological indexes, and steamed bread properties –48.In the traditional wheat flour dough, gliadin is a monomer protein with a small molecular weight . The comDough rheological properties and the properties of CSBs were affected when adding coarse cereals , 53, 56.Oats, purple potatoes, mung beans, and other crops contain a large number of polyphenols, and the molecular side chain of phenols has a large number of hydroxyl groups. Hydroxyl groups belong to hydrophilic groups, which will compete for water with substances such as starch and protein. Polyphenols rich in flour will increase the water absorption of dough, resulting in a series of changes in the process of making CSBs. It has been reported that the hydroxyl and carboxyl groups of dissolved phenolic compounds could interact with water and indirectly interact with the hydroxyl groups of starch through a hydrogen bond, to change the properties of water and starch . Water sIn addition to the binding effect with water, it has been shown that phenolic compounds could hinder the formation of disulfide bonds between proteins, which is detrimental to the formation of protein network structures, leading to the reduction of dough strength, gas holding capacity, and specific volume of products . In addiEnzymes often play a vital role in the food system. Normally we separate the enzymes in food into endogenous enzymes and added exogenous enzymes, both of them have an important effect on the quality of cereal foods , 61. LipIn addition to this, the texture of the CSBs will be affected accordingly. During CSBs storage, the dextrinized starch (branched starch) network present in fresh CSBs gradually transforms into an extensive, partially crystallized branched starch network with original branched starch microcrystals acting as linkage zones , 64. In In the food system, non-starch polysaccharide (NSP) is mainly composed of cellulose, hemicellulose, pectin, and resistant starch. It can be divided into insoluble NSP and soluble NSP. In the process of making steamed bread, the non-starch polysaccharides that play a role mainly include dietary fiber, β-glucan (BG). Fiber is divided into soluble dietary fiber and insoluble dietary fiber. A large number of studies show that the addition of dietary fiber will increase the water absorption of dough .Soluble dietary fiber will intercept digestive enzymes after water absorption and expansion, thus inhibiting carbohydrate digestion and reducing GI. Hydrocolloids can strongly affect the secondary conformation of proteins and the hydration properties of gluten. As a kind of hydrocolloid, BG is tightly bound with large amounts of water in the dough. BG competes with protein for water absorption, which is detrimental to the formation of the gluten network and affects the dough formation time and stability.As mentioned above, the process of producing traditional steamed bread is mixing, kneading into a dough, proofing, and steaming . With thDough in pasta processing is a complex mixture of flour, water, yeast, salt, or other ingredients and is the essential transition form of wheat from flour to food . When whTherefore, the research on dough products cannot avoid relating all of these indicators. Most of the researchers use rheological indicators such as dough flouriness, stretching, kneading, and foaming as the leading quality indicators.Rheology is a subject that studies the flow and deformation of materials. In the load curve of dough, the relationship between stress, strain, and time and the resulting elasticity, viscosity, plasticity, and other properties are called the rheological properties of dough , 74.In the process of kneading wheat flour into dough with water, the instruments used to reflect and test the rheological properties of dough mainly include the farinograph . The indDough rheological properties are affected when coarse cereals flour is added, this may be caused by the weakening of protein cross-linking due to the high fiber content in coarse cereals competing for water. Similar effects have also appeared in other studies. Compared with wheat, millet have higher water absorption, water solubility, and oil absorption index . The watResearchers conducted numerous investigations into the mechanisms behind the change in dough properties. With the addition of oat flour and oat bran, the β-glucan content of the mixed flour dough increased significantly. As we have mentioned that β-glucan could interact with water and result in higher water absorption. As with many other indicators, water absorption is not influenced by one cause only , 79. OncThis phenomenon can be corroborated by the breakdown values, as more flour was replaced, the content of gluten protein in the mixed flour became less, which gradually reduces the viscoelasticity of the dough. Therefore, in the viscosity measurement, the viscosity of the mixing system of flour and water became weaker and more prone to collapse. Thus, the breakdown value becomes larger.As The main effect should be attributed to starch, crops contain different starch, mainly reflected in starch particle size, starch type (amylose and amylopectin), and damaged starch content. As there are significant differences in starch particle size, crystallinity, fine structure, and straight chain starch content between sources, which can cause large differences in pasting parameters , 82, 83.Starch from various sources has different qualities, especially in gelatinization characteristics, crystal structure, particle size, chain length distribution, and anti-enzymatic hydrolysis characteristics. If there is a discrepancy between the indicators mentioned above, in the human body, the rate of digestion of starch changes as well , 86.When analyzing the rheological properties of doughs, the indicators water absorption (WA), dough development time (DDT), and farinograph quality number (FQN) are interlinked. When researching on coarse cereals pasta products, it is essential not only to analyze the effects of the components of the cereal but also to link these indicators together and analyze the specific patterns that can be applied in future studies.The gelatinization characteristics of wheat flour were measured by running a heating-holding-cooling program with a viscometer and recording the torque magnitude. In this testing process, the pasting temperature, peak viscosity, peak viscosity time, breakdown value, holding viscosity, final viscosity, and setback value of flour or starch can be obtained through data processing .As shown in The analysis of a large number of articles showed that the type  and characteristics  of the starch have a significant influence on these indicators. when the starch particles are uniform, it seems that researchers easier to get a regular and characteristic result, when the size and shape of starch particles are different, their gelatinization and retrogradation characteristics will be more difficult to predict .2 gas during the fermentation process to obtain a loose and porous dough structure, and a good fermentation can significantly improve the quality of the bread , redness-greenness (a*), and yellowness-blueness (b*). For the darker crumbs, some researchers believe that this is since that they have more prominent particles, which produce larger and darker shadows in the structure of the CSBs. In a related study of buckwheat CSBs, when the substitution level reached 70%, the brightness was significantly reduced by 28%.In terms of color, after adding coarse cereals flour, especially Tartary buckwheat flour, the b* was markedly higher, and the L* and a* were significantly lower than those of ordinary wheat flour products, which indicated that the addition of Tartary buckwheat would make the product darker and light green.Another reason for the reduction in brightness may be that the added oat flour is rich in BG. As shown in Texture analyzer is a kind of test for hardness, brittleness, elasticity, resilience, adhesiveness, cohesion, viscosity, bending ability, breaking/breaking force, brittleness, chewability, stickiness, tensile strength, elasticity, etc., these data were often used in experimental design to measure the quality of steamed bread.Coarse cereals flour tends to have higher dietary fiber content, and as the level of addition increases, the textural properties of the steamed bread changed, Abundant studies have shown that the addition of coarse cereals flour changed the secondary structure of proteins and disrupts the network structure of gluten . This wiAs mentioned earlier, the starch type is also an important factor, as shown in The addition of coarse cereals always leads to deterioration in the quality of CSBs, and this deterioration is usually related to the level of added cereals, some of which become unpopular with consumers because of their own anthocyanins and other substances, and some because the addition of coarse cereals dilute the gluten structure leading to a decrease in gas-holding properties, a decrease in CSBs specific volume and a darkening of color.In vitro digestion is usually used to simulate the process of food digestion in the human body  of coarse cereals CSBs, and the effects of long-term consumption of coarse cereals CSBs on diabetes, hyperglycemia, hypertension, and other diseases. It is believed that these studies can promote coarse cereals CSBs as a staple food for sub-healthy people.In conclusion, coarse cereals CSBs are a promising healthy staple food due to the unique nutritional value of each coarse cereals. With specific descriptions of human health benefits and superior product quality, it is believed that coarse cereals CSBs will occupy a unique position in the market.YY: acquisition of data and drafting the manuscript. XW: revising the manuscript critically for important intellectual content. Both authors contributed to the article and approved the submitted version.