The starch type and pre-treatment significantly influenced the properties of the foam. Pregelatinized starches exhibited slightly higher densities due to lower foamability caused by higher viscosity. Using starch exhibiting total loss of birefringence led to denser foams with greater compression properties than those with starch with a certain degree of crystallinity remaining. Therefore, selecting the appropriate starch type is crucial when developing starch-based materials to ensure optimal material and processing properties align with application requirements.Incorporating biopolymers in packaging foams can contribute to a more circular packaging system, utilizing renewable and compostable materials. Gelatin, with its favorable physicochemical properties, allows for producing gelatin foams via mechanical foaming, a well-established and low-investment process. To improve foam properties, starch can be added to the gelatin formulation. However, the variability in the properties of starch powders can impact the polymer blend and, consequently, the properties of the dry foam. This study aimed to investigate the impact of different starch powders from different botanical origins (tapioca and corn) and treatments (native or pregelatinized) on the properties of gelatin–starch foams produced by mechanical foaming. The study successfully produced foams with densities of approximately 45–50 kg/m Foams are cellular solids that can be found in many forms, both naturally and through human-made materials. Natural foams include those found in animal bone structures, marine organisms such as sponges and plant materials such as cork. Meanwhile, foams made from ceramics, metals and plastics are commonly used in various industrial applications. Plastic packaging foams are widely used for different applications, including food containment and thermal/mechanical protection for the delivery of food products. These plastic foams exhibit excellent properties  and are mainly made of petroleum-derived feedstocks, such as polystyrene (PS), polyethylene (PE) and polyurethane (PU). However, while these are recyclable materials, a considerable amount of plastic packaging waste leaks from the waste management systems and pollutes our ecosystems . The principles of the circular economy promote resource efficiency and waste reduction by keeping materials in use for as long as possible. Utilizing renewable and compostable biopolymers in packaging foams aligns with these principles, providing a sustainable and resource-efficient system that reduces waste and promotes long-term environmental sustainability. Additionally, biopolymers tackle the biocompatibility issues raised by conventional plastics  and are In recent years, considerable research has been conducted on developing biofoams for packaging applications. Starch-based foams have been extensively researched as an alternative to conventional plastic foams, with different processing methods, such as extrusion and baking, yielding promising results ,6,7,8. MHowever, implementing biofoams as bioplastics has encountered several challenges, including their high cost compared to their fossil fuel counterparts, low manufacturing efficiency and uncertainty on how to dispose of them after use . Thus, dGelatin is a by-product of the food industry used and investigated for numerous applications, such as biomedical products, packaging or tissue engineering. Gelatin is an ideal candidate for biomaterials development due to its outstanding properties: relatively easy processability, availability, low cost, biocompatibility and biodegradability . In addiGelatin powder  122,400 g/mol, isoelectric point 4.8, Dongbao Bio-Tech Co. Ltd., Baotou, China) is from a mixture of cow and pig bones. The moisture content of the as-received material was 11%, measured with a moisture analyzer .Four commercial starch powders were used: native tapioca (NT), pregelatinized tapioca (PT), native corn (NC) and pregelatinized corn (PC) starches. NT, PT and NC starches  and PC starch  were supplied by different suppliers. The native-pregelatinized starch powder pairs studied here did not come from identical harvesting batches; thus, while they come from the same species, inevitable variability in physicochemical properties is expected due to harvesting, climatic and genotypic differences . Table 1Sodium dodecyl sulfate (SDS)  and deionized water was used as a solvent. Tap water was used as the primary source of water for all experiments. Tap water was chosen due to its availability and low cost and its comparability to the type of water typically used in the community where the research was conducted.The preparation of the foams consisted of the following stages: (a) Thermoplastic starch (TPS) preparation, if required, (b) additives mixing (gelatin and SDS), (c) mechanical foaming with gas injection, (d) casting and (e) drying. In terms of the physical state of the materials, the process consisted of four stages: (a) liquid stage (during the additives mixing stage), (b) liquid foam stage , (c) gel foam (following the casting stage) and (d) dry foam .It is necessary to disrupt the crystalline starch structure by heating and shearing treatment to obtain an amorphous paste suitable for materials processing, the so-called thermoplastic starch (TPS). Thus, the starch powders were heated and mixed in water with a weight ratio of 1/10 (starch/water) at 80 °C for 20 min in a stirring reactor  at a 50 Hz stirring frequency. The starch suspension was then sheared at 80 °C for 10 min with an electric hand blender with a blade accessory  until a homogeneous starch paste was obtained. The gelatin, SDS, water and the TPS (if required) were added to the stirring reactor and mixed for 30 min at 60 °C. The mixtures were then foamed with a foam generator  at a liquid flow rate of 50 kg/h, 1000 rpm stirring speed and 45 °C. After foaming, the liquid foams were immediately cast in 15 × 15 × 5 cm rubber molds and let dry in an environmental chamber at 23 °C and 20% RH. Once dried, the foams were stored for at least 21 days under controlled conditions (23 °C and 50% RH) before characterization, when the degree of retrogradation of starch is expected to plateau .The X-ray diffraction (XRD) spectra of the starch powders were recorded using a diffractometer  with Kα copper radiation, 40 kV voltage and 20 mA current. Assays were performed for 2θ between 3 and 75° with steps of 0.05 °/s. The XRD patterns were truncated to the 4–35° region of the diffraction angle (2θ) and smoothed by applying the Savitzky–Golay filter with a polynomial of degree equal to 3 and 20 points. The linear baseline correction was then applied to the data points of the selected region, offsetting to a zero-intensity value and intensity normalized between 0 and 1 of arbitrary units (AU). The degree of crystallinity was estimated using the method proposed by Nara and Komiya , calculaThe morphology of the starch powders was studied through a Scanning Electron Microscope (SEM)  operating at an accelerating voltage of 5 kV. The samples were coated with a thin layer of gold using a sputter coater  to minimize electrical charge during observation.DSC measurements were conducted using a differential scanning calorimeter . Approximately 3 mg of starch/water suspensions with 10 wt.% starch content were placed in a hermetically sealed aluminum pan and equilibrated for 1 h at 23 °C. The pan was then ramped from 23 °C to 100 °C at a constant heating rate of 10 °C/min under a nitrogen atmosphere (50 mL/min) in a single cycle to determine the glass transition temperature of the suspensions.The starch powders in a 10 wt.% water solution before thermal and mechanical treatment and the starch pastes after TPS processing were observed by an optical microscope  using a regular and polarized light filter equipped with a digital camera. −1 to 1000 s−1 with 60 measuring points in 600 s. The viscosity of the formulated liquids was measured at 45 °C using a rheometer  equipped with a Peltier temperature control system. The solutions were loaded into a 45 °C pre-heated double gap cup (3 mL capacity) and stabilized for 60 s. The measurements were performed using an isothermal shear rate ramp test (45 °C) from 0.01 sThe surface tension of the formulated liquids was measured at 45 °C by the Wilhelmy plate method using a tensiometer . The strength of the gelatin and gelatin–starch gels was measured using a texture analyzer . The formulated gelatin and gelatin–starch solutions were prepared according to the Bloom test method, typically used to measure the strength of gelatin gels . The gellρ and lfρ are the density of the liquid before foaming and the density of the liquid foam immediately after foaming, respectively.The expansion ratio of the liquid foams was calculated using Equation (1) , where Eρ*) was determined according to the ISO 845:2006 standard by calculating the ratio between the mass of a dry foam sample and its volume. At least five specimens from each formulation were measured. The relative density (rρ) was calculated by dividing the bulk density of the foam by that of the dry solid from which the cell walls were made (Sρ), which was obtained by casting the gelatin and gelatin starch gels and calculating the ratio between their weight and volume, measured by the glass bead displacement method. Finally, the porosity of the solid foam (P) was determined from Equation (2) [The dry foam bulk density (tion (2) :(2)P=1−ρThe cellular structure of the foams was determined using an optical microscope . The camera was set up at 2592 × 1944 pixels. The surface of each specimen was colored using black ink to facilitate the visualization of the cellular structure. The mean pore area (an average of 600 measurements), mean cell area (an average of 300 measurements) and cell struts thickness of the foams were calculated using the ImageJ software. 2 area and 25.5 mm height. The compressive strength and Young’s modulus were derived from the stress–strain curves averaging the measurement results of five specimens. In addition, the foams’ elastic and plastic energy absorption was calculated by integrating the area under the stress–strain curve at the yield strain (or 10% strain if the sample did not exhibit a yield point) and 50% strain, respectively. The compression properties of commercial EPS cushion packaging blocks of 20 and 30 kg/m3 were also measured for comparison.The compression tests of the foams were conducted according to the ASTM D-1621 standard. A universal testing machine  with a 10 kN-load cell and a crosshead speed of 2.5 mm/min was used to characterize square foam specimens with a 100 cmp = 0.05) was performed using Minitab 17.1.Analysis of variance (ANOVA) with , peak (Tp) and concluding (Tc) transition points in the native starches , and their viscosity, surface tension and foamability  were investigated and compared to those from 20 wt.% and 25 wt.% gelatin content solutions. The foaming parameters  were optimized and standardized to create monodisperse and stable high-expansion foams. A foaming temperature close to the dispersions’ gelling point  was seleF3–16 = 6.99, p = 0.0032), mainly determined by the liquid’s viscosity  and surface tension . The suspensions prepared from native tapioca achieved the highest expansion ratio after mechanical foaming (10.31), mainly due to their relatively low viscosity (1768 mPa·s), the lowest among the ones made with starch. On the other hand, the lowest expansion ratio corresponded to the pregelatinized corn suspensions (8.88), which also displayed the highest viscosity among the studied dispersions. As seen in These results proved that slight viscosity and surface tension changes between formulated liquids lead to slight differences in expansion ratios. Higher expansions are obtained from liquids that facilitate the gas incorporation into the matrix, allowing the gas bubbles to expand and stretch. Thus, liquids with higher viscosities require higher energy to create enough shearing to introduce air into the liquid, limiting the capacity to achieve higher air volume fractions in the liquid foam. Higher energy in the process involves the modification of the foaming parameters, including faster stirring speeds and higher foaming temperatures, but the study of their impact on the liquid foams’ properties is beyond the scope of this paper.F3–16 = 49.27, p < 0.001), with those prepared with pregelatinized tapioca being the strongest and those prepared with pregelatinized corn the weakest. In addition, the effect of incorporating starch into formulations with 20 wt.% gelatin decreased its gel strength for native tapioca and pregelatinized corn and increased it for pregelatinized tapioca and native corn.As expected, the gels prepared with higher gelatin concentrations produced stronger gels . The typ3, was comparable to those achieved in conventional plastic foams used for packaging applications and corresponded to 20 wt.% gelatin foams, with an ER of 13.66 (see Bulk density and ER exhibited a negative linear correlation (r = −0.9825), and as expected, lower-density foams were achieved at higher ER as drying shrinkage was insignificant in all the formulations (<5 vol.%). The lowest density achieved, 30.21 kg/m3.66 see . The density of the gelatin foams considerably increased when their solid content increased from 20 wt.% to 25 wt.% due to the lower ER in the 25 wt.% gelatin solutions due to a considerable viscosity increase.F3–16 = 9.87, p < 0.001). Those foams made with tapioca starches had slightly lower bulk density than those made with corn starch: 44.03 kg/m3 (ER = 10.31) for native tapioca, 45.61 kg/m3 (ER = 9.60) for pregelatinized tapioca and 48.20 kg/m3 (ER = 9.42) and 49.45 kg/m3 (ER = 9.64) for native and pregelatinized corn, respectively. As expected, the pregelatinized starches produced foams with slightly higher densities than their native counterparts because their formulations were more viscous and led to lower ERs. The starch type significantly affected the bulk density of the foams (3), they were reasonably light for packaging applications. In addition, while no attempt was made to optimize the foaming parameters further, there is scope for density reduction by modifying the mechanical foaming and the formulation parameters.While the gelatin and gelatin–starch foams exhibited a relatively higher density than packaging EPS foams .The foam structure is highly dependent on the expansion ratio of the suspensions and the factors arresting and delaying foam aging . All the foams investigated in this research exhibited a heterogeneous open cell structure with an average cell size ranging from approximately 0.5 to 1.5 mm and relatively wide cell size distributions see . Gelatin2). This is attributed to their faster gelation than the rest of the foams due to their higher gelatin content (the other formulations had 20 wt.% gelatin content) [2) and a relatively high mean cell area due to exhibiting the highest expansion ratio. Lower mean pore areas and narrower cell area distributions generally led to higher bulk densities. The 25 wt.% solid content foams made solely with gelatin presented the smallest mean cell area (0.775 mmcontent) , which sF3–2396 = 36.41, p < 0.001) and cell areas  due to their lower viscosities that facilitated the gas incorporation into the solution and, thus, the elongation and growth of the foam cells. For the same reason, the foams made with the native starches also exhibited broader cell size distributions compared to the pregelatinized counterparts  characterize the foam behavior as the cell structure collapses. The starch type significantly impacted the mechanical properties of the foams , the quality of the thermoplastic starch preparation process being the most significant factor. The foams prepared with native tapioca, whose TPS exhibited a certain degree of crystallinity manifested by remaining starch granules displaying the characteristic Maltese cross  also significantly impacted foam properties. Foams made with TPS  exhibited total loss of birefringence and resulted in denser foams with higher compression properties. However, foams made with native tapioca displayed a certain degree of crystallinity and showed the lowest compression modulus and strength. Thus, a careful selection of the starch type is crucial to optimize starch-based materials’ properties and processing parameters for specific application requirements.


The structural control over silica synthesis achieved by these precursors is highly sensitive to pH and solvency. Alkoxysilanes derived from the sugar alcohol glycerol (diglycerylsilane) react more slowly and with much less sensitivity to pH. We report that, in the presence of cooled aqueous starch solutions, glyceroxysilanes undergo transesterification with the sugars on starch, leading to (hollow) microtubules resembling worms of about 400 nm in diameter. The tubes arise from the pre-assembly of starch bundles, which occurs only well below room temperature. It is straightforward to treat the first-formed starch/silica composite with the enzyme amylase to, in a programmed fashion, increasingly expose porosity, including the worm morphology, while washing away untethered silica and digested starch to leave an open, highly porous materials. Sintering at 600 °C completely removes the starch silane moieties.Many strategies have been adopted to prepare silica materials with highly controlled structures, typically using sol–gel chemistry. Frequently, the alkoxysilanes used in sol–gel chemistry are based on monoalcohols, e.g., Si(OEt) An enormous literature, including the comprehensive book by Iler , exists Materials scientists have spent considerable time searching for synthetic strategies that permit the controlled assembly of siliceous structures for a variety of purposes that ranging from reinforcement provided by very small, essentially pore-free particles (often found as aggregates) of fumed silica to model colloidal systems formed via the Stöber process , which i2 and other metal oxides have been grown ..4), or iIt was of interest to explore if, rather than entraining proteins or polysaccharides in silica, it would be possible to benefit from the properties of DGS while templating the polysaccharide starch. We report the formation of starch-templated silica and microscale worm-like morphology that were revealed once the starch was partly or completely digested by the enzyme amylase, but lost during calcination.Bacillus amyloliquefaciens was purchased from Sigma. Imidazole, calcium chloride, tetraethyl orthosilicate and glycerol  were purchased from Aldrich. All chemicals were used as received. Diglycerylsilane DGS was prepared according to published work [Soluble starch was purchased from BDH Inc. or Sigma Aldrich. α-Amylase from hed work ,31.1H, 13C and 29Si NMR spectra were recorded on a Bruker Avance 600 MHz nuclear magnetic resonance spectrometer using chloroform-d. A thermogravimetric analysis (TGA) was performed using a Thermowaage STA409. The analysis was measured in air, with a flow rate of 50 mL/min. The heating rate of 10 °C/min was used from room temperature to 900 °C. DSC were recorded on TA instruments DSC 2910 using standard DSC cell. SEM photographs were observed using JEOL JSM-7000F Field Emission Analytical Scanning Electron Microscopy.2 sorption measurements, all the samples were degassed at 100 °C under vacuum overnight. Nitrogen adsorption–desorption isotherms were recorded on a Quantochrome Nova 2000 instrument. The specific surface area was calculated using the multipoint Brunauer–Emmett–Teller (BET) method. Pore size distributions were calculated by the Barrett, Joyner and Halenda (BJH) method. Pore volumes were determined from the amount of N2 adsorbed at P/P0 = 0.99.Prior to NStarch solutions were freshly prepared by dissolving soluble starch in water at 90 °C for 10 min, at specified weight ratios of 30 and 40%, respectively, and kept warm (90 °C) before use.W1  was dissolved in DI water (0.50 mL) using an ultrasonic bath for 20 min at 0 °C. The resulting sol was mixed with starch solution (starch 0.15 g and water 50 mL). The mixture was allowed to stand at 0 °C for 30 min then at −10 °C for 1 h, and allowed to warm to room temperature overnight, leaving gels that ranged from translucent to opaque W1 . It could be stored in a sealed container at this stage. The process was repeated with higher starch loading  to produce W2. Other ratios of DGS/starch/water were examined but did not lead to worm formation (Shown for entry W1 : DGS (0.ormation . Note th2O (10 mL) for 4 h, a process that was repeated 9 times over 2 d, each time with fresh water. W1 and W2 were incubated in imidazole-HCl buffer solution  containing α-amylase (0.2 g) at 40 °C for 20 h, washed by soaking in H2O (10 mL) for 4 h and repeated 5 times. The gel was then lyophilized (dried under vacuum) to give W1-A1 and W2-A1. Other samples were similarly exposed to these conditions, but worms were not revealed after digestion  solution containing α-amylase (0.2 g) at 50 °C for 20 h, washed by soaking in H2O (10 mL) for 4 h, a process that was repeated 5 times. The gel was then allowed to dry in air to produce W1-A2 and W2-A2, respectively.DGS. Note that, even with soluble starch, the specific batch and supplier can be important for morphologies of the resulting starch silica gels. After mixing with mechanical stirring, the solutions were cooled first to 0 °C and then −10 °C and left overnight at room temperature. The samples were repeatedly washed with water to remove glycerol and unreacted DGS and then lyophilized. A library of starch/silica composites was prepared, in which the relative concentrations of both DGS and starch were varied  most of these features are lost, consistent with an interface that is partly organic and, upon thermal stress, is able to undergo further metathesis/condensation reactions as the organic constituents are lost, leaving only silica behind  the outer, air-exposed layer that, while porous, did not undergo significant changes during enzymatic degradation; (B) a narrow band exhibiting slightly higher porosity, (C) a large domain where significant quantities of starch had been removed and the porosity was increased; and (D) the unmodified starch silica . The imp−1, In selected samples, worm-shaped morphologies were exposed upon the partial removal of starch by amylase digestion at a lower temperature of 40 °C; secondary enzymatic treatment of these samples at 50 °C led to even more open structures with a higher fraction of ‘worms’ and lower quantities of background material. That is, the background matrix of starch and any silica or small elements are removed during amylase digestion, but the tubes/worms are not subject to enzymatic degradation. SEM images reveal that the starch–silane microtubes are highly uniform and about 400 nm in diameter. They appeared curving and entangled on the surface of porous matrix, suggesting some level of flexibility ; many apW1 vs. W2 samples). A much higher yield of microtubes was obtained in the ratio of 2:0.15. Second, after mixing the starch and DGS, it is necessary to cool the mixture below 0 °C and allow the samples to anneal. Only when both of these conditions were met were the worms observed.We note that two factors are required if the worm-like morphologies are to form within the silica matrix: starch/ratio; and temperature. First, the influence of the silica/starch ratio on the formation of worm-shape microtubes was investigated at different Si/starch (mmol/mass (g)) ratios of 2:0.1 ➞ 2:0.4 . HoweverDGS has a C:O:Si ratio of 36.7:48.9:14.3 and starch a C:O ratio of 48.7:51.3. Thus, a small fraction of silicon is proposed to bridge starch assemblies to create these worms. A ‘model’ structure—which is entirely speculative—that has the correct elemental ratio is shown in The nature of the worm materials was probed using an EDX analysis . A compaW2; −4.7% for W2-A1; and –6.5% for W2-A2. The second mass loss greatly differentiated samples that had undergone partial or complete enzymatic digestion. The as-prepared materials showed further weight loss of −57.8% (W2), while lower losses were observed for once- −26.87% (W2-A1) and twice-digested −19.2% (W2-A2) samples between about 150 and 600 °C. This loss is ascribed to starch carbonization and combustion, as could be seen from the TGA data of starch gel alone, which showed 100% mass loss by 600 °C. That is, oxidizable carbon is removed from these samples by enzymatic digestion prior to the TGA measurement.TGA analyses of the worm-containing samples are summarized in Nitrogen absorption data revealed Type IV isotherms with a single hysteresis loop for all samples. BJH pore size distributions show that almost no micropores smaller than 2 nm are present B,C. WithHs), the process is typically ‘one-way’. The equilibrium lies very far towards the product silanol  groups, complete hydrolysis is essentially paralyzed.In addition to the hydrolysis/condensation and KDGS formulation, one may decide what final porosity is desired and tune the amount of enzymatic degradation to perform accordingly.Within the starch/silica composites formed are three types of materials: unmodified starch, untethered silica  and silane-modified starch. Digestion with amylase degrades the starch, leading to an increase in porosity per se and a loss of silica that has not been integrated into the monolithic structure. Thus, materials created with higher initial starch loading became more porous upon enzymatic degradation, as there was more material to be lost . SequentWith traditional porogens such as poly(ethylene oxide), the porosity of silica monoliths is controlled through a combination of sol–gel processes generating silica, and concurrent microscopic/macroscopic phase separation. After removal of the water-soluble PEO phases by washing or sintering, the remaining hierarchical porous structures often contain micro, meso and macropores ,32. Rmin (minimum radius) of about 2.4 nm—there is a physical limitation for its ability to access all starch-occupied pores. This inaccessibility accounts for the ~19% starch after digestion that remains in pores that are too small for the enzyme to access.In silica–starch systems, there are almost no micropores smaller than 2 nm present after either amylase digestion or sintering, which suggests that the sizes of starch gel that acts as a template are larger than 2 nm. PEO, of course, is water soluble and does not have such geometric constraints. Similar to silica-PEO systems, there is no direct relationship between mesopore sizes and starch gel fraction. The increase in pore volume that accompanied more starch in the starting formation is most likely due to a change from particle aggregate to bi-continuous porous structures that can be seen in the SEM images . With am4 4 A—is more4 B. In add4 C is lessThe worm moieties are neither silica nor starch but a composite of the two. The elemental analysis suggests that, after untethered starch was enzymatically removed, the resulting worms possessed more silicon than starch but much less than silica . We propW2-A2, Starch is a polysaccharide containing branch amylopectin and linear amylose; the latter is composed of D-glucose repeat units in (α1→4) linkages. Soluble starch contains a high percentage of linear amylose, which governs its properties . We infeDGS, and product, are very rich in natural materials, which is one of the objectives of more sustainable materials [There are several attractive features of this process to make structured organomodified silica: the starting materials are readily available and very inexpensive; the process is synthetically trivial; and one can tune the porosity of the silica composite using initial formulation, particularly starch content, and the degree of thermal degradation of the starch constituent. Perhaps most attractive, however, is the ability to control the morphology, including porosity of the monolithic structures, by using different enzymatic degradation conditions; materials with different porosity and density can be formed, including worms. In addition, the starting materials, starch and aterials .


The study aims to propose an optimal workflow in patients with a PI‐RADS 3 (PR‐3) assessment category (AC) through determining the timing and type of pathology interrogation used for the detection of clinically significant prostate cancer (csPCa) in these men based upon a 5‐year retrospective review in a large academic medical center.F‐test.This United States Health Insurance Probability and Accountability Act (HIPAA)‐compliant, institutional review board‐approved retrospective study included men without prior csPCa diagnosis who received PR‐3 AC on magnetic resonance (MR) imaging (MRI). Subsequent incidence and time to csPCa diagnosis and number/type of prostate interventions was recorded. Categorical data were compared using Fisher's exact test and continuous data using ANOVA omnibus n = 55), another diagnostic procedure was required to diagnose csPCa in 42/55 (76.4%) of men, compared with 3/21(14.3%) men with an initial MR targeted‐biopsy approach (n = 21); (p < 0.0001). Those with csPCa had higher median serum prostate‐specific antigen (PSA) and PSA density, and lower median prostate volume (p < 0.003) compared with non‐csPCa/no PCa.Our cohort of 3238 men identified 332 who received PR‐3 as their highest AC on MRI, 240 (72.3%) of whom had pathology follow‐up within 5 years. csPCa was detected in 76/240 (32%) and non‐csPCa in 109/240 (45%) within 9.0 ± 10.6 months. Using a non‐targeted trans‐rectal ultrasound biopsy as the initial approach (Most patients with PR‐3 AC underwent prostate pathology exams within 5 years, 32% of whom were found to have csPCa within 1 year of MRI, most often with a higher PSA density and a prior non‐csPCa diagnosis. Addition of a targeted biopsy approach initially reduced the need for a second biopsy to reach a for csPCa diagnosis. Thus, a combination of systematic and targeted biopsy is advised in men with PR‐3 and a co‐existing abnormal PSA and PSA density. Further assessment with biopsy has been considered as crucial by some,In this large retrospective study, our primary goal was to determine the timing, rate and type of prostate pathology interrogation in a PR‐3 AC patient population and to propose an optimal workflow in these men. A secondary goal was to determine risk of csPCa based on prior prostate biopsy status.2Institutional review board approval was obtained for this United States Health Insurance Probability and Accountability Act (HIPAA)‐compliant retrospective study, and written informed consent was waived.2.1Patients were identified from our electronic medical record (EMR) using our institutional search engine, Apache Solr server . We retrospectively identified all patients who underwent prostate mpMRI between 1 July 2014 and 22 August 2019, in whom PR‐3 was the highest AC reported. Regular expression matching was used to identify PR‐3 patients, while excluding patients who also had PR 4 or 5 lesions. This was also verified manually on the MRI reports. Patients who had a prior diagnosis of csPCa (Gleason Score [GS] ≥ 3 + 4) and those with any treatment for PCa prior to mpMRI were also excluded. Evaluation for the presence, number and type of subsequent pathology evaluation of the prostate was determined with EMR review up to the end of the study timeline (February 2020), which was on average 30.6 ± 14.8 months after the mpMRI. Patients who had pathology follow‐up were classified into three groups according to their clinical status: (1) prior negative biopsy; (2) on prior non‐csPCa diagnosis (GS = 3 + 3); and (3) biopsy naïve patients.2.22) and prostate volume were obtained from a combination of the MRI report and EMR review. The zonal location of the PR‐3 index lesion  was recorded.All MR imaging was performed at 3T  per PI‐RADS v2 MR technical specifications. The PIRADS AC was retrospectively collected from the MRI report via the EMR. All prostate MR interpretations were provided by abdominal fellowship‐trained faculty radiologists with a range of 3–20 years of experience in reading prostate MRI in a high‐volume prostate MRI academic center. Patient age, serum prostate‐specific antigen (PSA) (ng/ml), PSA density  and any type of prostate surgery resulting in pathological analysis . We included therapeutic surgical cases for longitudinal completeness, recognizing that these procedures were not performed for diagnosis.At our institution, fusion‐bx was performed under ultrasound guidance in real time through fusion of pre‐biopsy MRI images, using one of two advanced fusion systems: UroNaV system (Phillips) and Koelis Inc. MRI‐bx refers to in‐bore trans‐perineal biopsy with MR imaging in real time.2.4Patients were classified into three categories based on their final pathological outcomes: (1) csPCa, (2) non‐csPCa or (3) no PCa identified. The presence of a GS ≥ 3 + 4 = 7 in any core was considered csPCa as per PI‐RADS V2.0. For those who developed csPCa, the number and type of pathological confirmatory prostate procedures after the mpMRI was analysed. The highest GS was determined using whole gland prostatectomy over biopsy when available, or the highest GS from all prostate biopsies when no prostatectomy was performed. The analysis was based on a per‐patient basis. As this is a retrospective study, the pathology reports and histology slides were not re‐reviewed.2.5F‐tests. When comparing PSA, prostate volume and PSA density among study groups, a log transformation was used for valid inference; these data are presented on their original scale. A Pearson's χ2 test was used to test for a difference in the proportion of initial biopsies that resulted in a second biopsy by biopsy type (TRUS‐bx first vs. a targeted [MRI‐bx or fusion‐bx] approach first). Normal 95% binomial proportion confidence intervals (CIs) were used to define the precision around the observed incidence of csPCa. The association between the number of prostate procedures and the diagnosis of csPCa, non‐csPCa or no PCa was measured using robust Poisson regression with a log link. All testing was two‐tailed, and p‐values < 0.05 were considered statistically significant. Analysis was performed using SAS 9.4 . The relationship between PSA density and detection of csPCA was determined using a binary logistic regression model to obtain the predicted probabilities with 95% CIs.Descriptive statistics are presented as means and standard deviation, or medians with interquartile ranges for continuous data and as frequencies with percentages for categorical data. Comparisons of categorical data were made using Fisher's exact tests and continuous data using ANOVA omnibus 33.1n = 74) or a prior PCa treatment (n = 17). Out of the remaining 332 patients, 92 (27.7%) did not have any prostate pathology follow‐up within the study timeframe after mpMRI. Thus, the remaining 240/332 (72.3%) of men all had prostate pathology data available and formed our study cohort. Their mean age were 63.1 ± 7.3 years and mean PSA was 6.7 ± 5.7 ng/ml. Of the patients, 10/240 had a prior mpMRI study, 4 of whom had a prior negative biopsy and 6 of whom had a prior non‐csPCa diagnosis. Our study cohort underwent a total of 350 prostate procedures after receiving an MRI P3‐AC, which included 285 biopsies . The mean number of cores per biopsy were as follows: fusion‐bx = 14.1 ± 3.4 cores; TRUS‐bx = 12.2 ± 2.9 cores; MRI‐bx = 8.0 ± 5.3 cores. There were 58 radical prostatectomies and 7 TURPs  received a PR‐3 AC  in this large tertiary academic center study , the incidence of csPCa was 23% . More precisely, for those with pathology follow‐up after the MRI (n = 240), the incidence of csPCa was 76/240 = 32% . In those with subsequent csPCa diagnosis (n = 76), csPCa was detected based on prostate biopsy in 56/76 (73.7%) of cases  while csPCa was confirmed with prostatectomy in 20/76 (26.3%).Considering the entire PR‐3 population (p < 0.0001).Of those diagnosed with csPCa on follow‐up biopsy, 21/76 (28%) initially underwent targeted biopsy (18/21 [86%] fusion‐bx and 3/21 [14%] MRI‐bx) as the first biopsy approach, while 55/76 (72%) underwent only systematic non‐targeted TRUS‐bx. Only 3/21 (14.3%) of those who underwent initial targeted biopsy required another diagnostic procedure to reach the final csPCa diagnosis compared with 42/55 (76.4%) of those who initially underwent only systematic TRUS‐bx. This need for an additional biopsy between those who underwent TRUS‐bx only versus included targeted biopsy as a first method of choice was statistically significant  months after the mpMRI. The overall average follow‐up time of the study was 9.9 ± 12.0  months after the mpMRI.3.3The factors associated with a subsequent csPCa diagnosis in this PR‐3 cohort are outlined in Table Forty‐two PR‐3 AC patients who were subsequently diagnosed with csPCa had a prior non‐csPCa diagnosis (55%). There was no difference in the mean age between patients with or without a subsequent csPCa diagnosis. The peripheral zone was the most common location for csPCa with 55 out of 76 index lesions located there (72.4%).3.4The incidence of csPCa according to prior clinical status was as follows: highest in the biopsy naïve group 25/72 = 35% ; followed by those with a prior non‐csPCa diagnosis 42/126 = 33%  and was lowest in the prior negative biopsy group: 9/42 = 21% .p < 0.001).Results based on baseline clinical status prior to mpMRI are outlined in Table Regarding PSA density, we found that there is a relationship between PSA density and the detection of csPCa; for instance, a median PSA density of 0.20–0.30 has a probability of approximately 0.6 for a subsequent detection of csPCa  not demonstrating any PCa on follow‐up, but 25/72 (33%) subsequently received a csPCa diagnosis.4The literature does not provide clear guidance regarding the management of MR‐detected PR‐3 AC lesions. The aim of our retrospective study was to determine the time and optimal diagnostic biopsy approach for detection of csPCa in patients who received a PR‐3 AC, excluding those with a prior positive biopsy for csPCA or prior treatment for PCa. We demonstrate that detection of csPCa in patients with an overall PR‐3 AC ranges from 21% to 35%, the former representing those with a prior negative biopsy and the later corresponding to those who were biopsy naïve. The average time to a subsequent csPCa diagnosis in these populations was short, at less than a year.As expected, we confirmed in these cohorts that a high PSA density, higher serum PSA and lower gland volumes at time of mpMRI are all more common in those with subsequent csPCa diagnosis. Additionally, we observed that the PSA density may have a prospective role in determining likelihood of csPCa detection, which is previously described in literature.Our analysis supports using a combination targeted systematic biopsy approach for diagnosis in PR‐3 AC cases. A targeted fusion‐bx approach was the most common diagnostic technique to arrive at a prompt csPCa diagnosis in PR‐3 lesions and reduced the need for further procedures, as described in other studies.p < 0.001) and lower prostate volume (p < 0.001) at the time of mpMRI, as supported by Hermie et al. Hansen et al.The risk of an underlying csPCa diagnosis after a PR‐3 score has been investigated by others, which support our study. Hermie et al.Others have found that there is a low likelihood of csPCa in PR‐3 lesions. Ullrich et al.Our study is unique in that as it was longitudinal, we were able to determine the average time to a subsequent diagnosis of csPCa. In this population (PR‐3 AC lesion), the time is short, at <1 year on average. This finding may be useful for follow‐up workflow planning; for instance, a yearly follow‐up MRI strategy may not be optimal for PR‐3 AC lesions.We included a mixed cohort of patients with prior negative, prior non‐csPCa and biopsy naïve patients as all represent patients that are often assigned a PR‐3 AC, and we found that a substantial number of patients in each of the three cohorts subsequently were found to have csPCa (21%–35%), which underscores the need for clinical follow‐up in all groups when diagnosed with a PR‐3 AC. However, a subsequent diagnosis of csPCA was most commonly seen in those who had a prior non‐csPCa finding on pathology.n = 92) of our original PR‐3 AC cohort did not undergo follow‐up pathological evaluation within the timeframe of this study and were not included in the final analysis. This is important to recognize, as 72% of patients with a PR‐3 AC in our tertiary center underwent pathology interrogation. It is possible that the desire to obtain pathological confirmation, without defined clinical guidelines, may be dependent on both patient and clinician preferences. The actual indication for performing the mpMRI studies was not made available for inclusion in our analysis. However, the prior clinical and radiological status of the patients were indeed analysed, which gives insight into why they may have been selected for MRI evaluation. For example, about half of the patients (52.5%) had a prior diagnosis of non‐csPCa. Finally, our PCa outcomes were based on a per‐patient basis. This is in support of the literature, considering recent findings that targeted biopsy is non‐inferior to initial systemic biopsy in the detection of csPCa, our study supports using targeted biopsy, but in addition to clinical biomarkers, such as PSA and PSA density.Our retrospective study has several limitations. First, we did not have a single expert radiologist re‐read all the MR studies to determine our PR‐3 AC cohort, but instead MR reports were read by multiple radiologists from a large tertiary academic center. This limitation does provide some benefits, however, as prostate MRIs read by a sole expert reader is not standard practice and assigning a PR‐3 AC is even more commonplace when studies are read by general radiologists.In conclusion, in our institution, most men with a PR‐3 AC have follow‐up prostate intervention within a year, one third of whom were subsequently diagnosed with csPCa, underscoring the importance of pathological follow‐up in the PR‐3 AC population. The majority of csPCa was detected in men with a prior non‐csPCa diagnosis and most commonly diagnosed via targeted biopsy, which reduced the need for further biopsy procedures compared with non‐targeted systematic TRUS biopsy alone. Thus, this study supports short‐term follow‐up and targeted biopsy in men with PR‐3, who also have an abnormal PSA and PSA density, as a first choice for detection of csPCa.Fiona Fennessy played the primary role in the study conception. Renato Umeton, Jonathan Waring and Andres Camacho were responsible for data collection with Andres Camacho and Fatima Salah contributing to additional manual clinical and radiology data collection from the electronic medical record. Michelle Hirsch and Massimo Loda contributed to histopathological data collection and analysis. Statistical analysis was performed by Camden Bay, and results were interpreted by Andres Camacho and Fiona Fennessy. Clare Tempany, Alexander Cole and Adam Kibel played a major role in adding clinical relevance to data interpretation. Fatima Salah, Andres Camacho and Fiona Fennessy prepared the draft manuscript. All authors reviewed the results and discussion, edited and approved the final version of the manuscript.Grant disclosures are added at the beginning of the article. The remaining authors have no disclosures or possible conflict of interest and/or commercial involvement related to contents of his manuscript.


Autism spectrum disorder (ASD) is a common neurological disorder. Although the etiologies of ASD have been widely speculated, evidence also supports the pathogenic role of cutaneous inflammation in autism. The prevalence of ASD is higher in individuals with inflammatory dermatoses than in those without inflammatory diseases. Anti-inflammation therapy alleviates symptoms of ASD. Recent studies suggest a link between epidermal dysfunction and ASD. In the murine model, mice with ASD display epidermal dysfunction, accompanied by increased expression levels of proinflammatory cytokines in both the skin and the brain. Children with ASD, which develops in their early lifetime, also exhibit altered epidermal function. Interestingly, improvement in epidermal function alleviates some symptoms of ASD. This line of evidence suggests a pathogenic role of cutaneous dysfunction in ASD. Either an improvement in epidermal function or effective treatment of inflammatory dermatoses can be an alternative approach to the management of ASD. We summarize here the current evidence of the association between the skin and ASD. For instance, the prevalence of autism spectrum disorder (ASD), also termed autism, is approximately 2.21% in adults . In chilASD includes non-syndromic and syndromic autism. The latter is mainly caused by chromosomal abnormalities or monogenic alterations . Regardi2.The pathogenic role of inflammation in ASD has been well demonstrated , 19. Ind2.1.p = 0.019) (p = 0.003)  . Althoug= 0.019) , Croen e= 0.019) . The sam= 0.003) . This ph= 0.003) . The lin= 0.003) . Similar= 0.003) . Second,= 0.003) . The inh= 0.003) . Similar= 0.003) . Collect2.2.p < 0.001) (p = 0.003)  (p < 0.001) (p < 0.05) (p = 0.003) (p = 0.04)  . Interes= 0.003) . On the 8–15.92) . Another< 0.001) . Atopic  < 0.05) . However < 0.05) , 52, 53.= 0.003) . But odd= 0.003) . Additio = 0.04) . Taken t2.3.in vitro and in vivo , indicating epidermal dysfunction in ASD. Most importantly, the ASD symptom such as the Social Responsiveness Scale was significantly improved following the correction of epidermal functional abnormalities with topical emollient (CURECODE®) twice daily for 2 months . The autism treatment evaluation checklist and repetitive behaviors scale-revised were also markedly reduced   . These r4.bacteroides fragilis alleviates ASD symptoms, improves gut permeability, and alters microbial composition in a mouse model of ASD induced by maternal immune activation   , even mifemales) . Finallyfemales) , 131 andfemales) , 132. He5.ASD is common in both adults and children. Although therapeutic regimens, such as medication and behavior management, are available, there are still challenges in clinical practice. Medicines, such as risperidone and aripiprazole, can cause some side effects, including somnolence, extra-pyramidal symptoms, hyperprolactinemia, body weight gain, headache, and urinary incontinence. , 134. MoThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.M-QM: Conceptualization, Writing – original draft, Writing – review & editing. SY: Data curation, Formal analysis, Investigation, Writing – original draft. TM: Writing – review & editing. GZ: Conceptualization, Data curation, Formal analysis, Writing – review & editing. TZ: Writing – review & editing, Conceptualization, Data curation.


The revision surgery rate was 3% . A lower rate of pseudomeningocele was observed with autologous duraplasty when compared with synthetic duraplasty (0.7% [95% CI 0–1.3%] vs. 5.3% [95% CI 2.1–8.4%] p < 0.01). The rate of CSF leak and revision surgery was lower after autologous duraplasty than after non-autologous dural graft . Autologous duraplasty is associated with a lower rate of post-operative pseudomeningocele and reoperation. This information should be considered when planning duraplasty after foramen magnum decompression in patients with CMI.Despite extensive investigations, the choice of graft material for reconstructive duraplasty after foramen magnum decompression for Chiari type I malformation (CMI) is still a topic of discussion. The authors performed a systematic review and meta-analysis of the literature examining the post-operative complications in adult patients with CMI after foramen magnum decompression and duraplasty (FMDD) using different graft materials. Our systematic review included 23 studies with a total of 1563 patients with CMI who underwent FMDD with different dural substitutes. The most common complications were pseudomeningocele (2.7%, 95% CI 1.5–3.9%,  Foramen magnum decompression with duraplasty (FMDD) is the most common treatment for adult patients with isolated Chiari type I malformation (CMI) and with syringomyelia-CMI complex . In factA comprehensive literature search of PubMed, Cochrane Library and Ovid SCOPUS was conducted for studies published from January 1990 to December 2022. PRISMA guidelines  demographic data; (2) mean follow-up; (3) surgical technique and graft material; (4) post-operative PSMC; (5) post-operative CSF leak; (6) post-operative infections; (7) number of reoperations ; and (8) post-operative aseptic meningitis. Graft materials were classified as follows: autologous, synthetic and biological nonautologous .The primary objective of this systematic review and meta-analysis was to determine the rate of PSMC, CSF leak, reoperation, aseptic meningitis and post-operative infections among adult CMI population treated with FMDD, and to examine the impact of different graft material on the outcomes.A modified version of the Newcastle–Ottawa Scale  was used2)  .Inter-observer agreement was tested with Cohen’s kappa coefficient (k). The Wald method was used to calculate confidence intervals (CI) for event rates. In order to assess the heterogeneity of the data, the Higgins index (I2)  was used applied . PredictStudies included in our systematic review are summarized in Twenty-three studies and 1541 adult patients with CMI that underwent FMDD were analyzed in this review.All articles presented a retrospective design. All studies were rated “high quality”. Inter-observer agreement was 0.88.The mean age of the included patients ranged between 31 to 50 years old, and the proportion of female patients was 72.1% (95% CI 69.9–74.3%). Associated syringomyelia was reported in 56.9% of cases (95% CI 54.2–59.4%). FMDD was completed with autologous graft in 602 patients , whereas a biological nonautologous graft or a synthetic graft were used in 331  and 617 patients , respectively .p < 0.01, I2 = 69%)   , and bacterial meningitis in 0.8% . Moreover, aseptic meningitis was reported in 0.6% of cases . When considering graft material, PSMC was significantly more common among the synthetic graft population when compared with autologous grafts . On the other hand, although the overall rate was higher among biological nonautologous grafts, the statistical analysis failed to find a significant difference between biological nonautologous and autologous grafts . Furthermore, post-operative CSF leak and the rate of reoperation were significantly more common among biological nonautologous grafts than in autologous FMDD . No differences were observed between synthetic and autologous grafts for the same outcomes   . Further2 = 43%)  and 3% (2 = 54%) , respects. 0.8%) . Similars. 0.8%) .2 was greater than 50% for the rate of reoperation and post-operative PSMC . Subgroup analysis showed that the biological nonautologous group and the synthetic group carried a high heterogeneity . Similarly, for reoperation rate, the synthetic group results increased the overall I2. In both cases, small studies increased the heterogeneity on the overall analysis  and data on how post-operative complications were assessed  were missing in some studies and were not included in our analysis. Similarly, no sufficient data on steroid use in the perioperative time frame were available.Our meta-analysis found that autologous duraplasty is associated with a lower rate of post-operative pseudomeningocele and reoperation when compared to synthetic and other biological grafts. In addition, autograft had lower CSF leak than other biological grafts. This information should be considered when planning duraplasty after foramen magnum decompression in patients with CMI.


Scientific Reportshttps://doi.org/10.1038/s41598-023-32568-7, published online 03 April 2023Correction to: The original version of this Article contained an error in the Data availability section, where the GEO accession number was omitted.https://www.ncbi.nlm.nih.gov/geo/). The whole genome sequencing data generated in this study have been submitted to the NCBI SRA database (https://www.ncbi.nlm.nih.gov/bioproject/) under accession number PRJNA832117, reviewer's accession link: https://dataview.ncbi.nlm.nih.gov/object/PRJNA832117. All original code has been deposited at Github .”“All raw and processed sequencing data generated in this study have been submitted to the NCBI Gene Expression Omnibus , under accession number GSE201435. The whole genome sequencing data generated in this study have been submitted to the NCBI SRA database (https://www.ncbi.nlm.nih.gov/bioproject/), under accession number PRJNA832117: https://dataview.ncbi.nlm.nih.gov/object/PRJNA832117. All original code has been deposited at Github .”“All raw and processed sequencing data generated in this study have been submitted to the NCBI Gene Expression Omnibus (GEO; The original Article has been corrected.


Producing starch gels with superior mechanical attributes remains a challenging pursuit. This research sought to develop a simple method using ethanol exposure to produce robust starch gels. The gels’ mechanical properties, rheology, structural characteristics, and digestion were assessed through textural, rheological, structural, and in vitro digestion analyses. Our investigation revealed an improvement in the gel’s strength from 62.22 to178.82 g. The thermal transitions were accelerated when ethanol was elevated. The exposure to ethanol resulted in a reduction in syneresis from 11% to 9.5% over a period of 6 h, with noticeable changes in size and color. Rheologically, the dominating storage modulus and tan delta (<0.55) emphasized the gel’s improved elasticity. X-ray analysis showed stable B- and V-type patterns after ethanol exposure, with relative crystallinity increasing to 7.9%. Digestibility revealed an ethanol-induced resistance, with resistant starch increasing from 1.87 to 8.73%. In general, the exposure to ethanol played a crucial role in enhancing the mechanical characteristics of kudzu starch gels while simultaneously preserving higher levels of resistant starch fractions. These findings have wide-ranging implications in the fields of confectioneries, desserts, beverages, and pharmaceuticals, underscoring the extensive academic and industrial importance of this study. Hydrogels are characterized as polymer networks that are hydrophilic and three-dimensional in nature. They possess a notable capacity to absorb and retain significant amounts of water or biological fluids. Their high water retention capacity, coupled with their inherent softness and flexibility, opens up numerous potential applications across various fields ,2. WithiDespite their promise, hydrogels’ poor mechanical and rheological properties frequently hinder their widespread industrial application. This shortcoming is generally linked to imperfections in the cross-linking process, leading to an inconsistent structural network. Moreover, inadequate energy dissipation mechanisms contribute to their poor resistance to mechanical stress and strain ,6. Thus,Scientists have been innovative in addressing these challenges, exploring structural designs and energy dissipation systems and incorporating techniques such as post-gelation treatments ,8. Post-Ethanol, a solvent that is semi-polar, water-miscible, and innocuous, presents an intriguing solution following the process of gelation. The dehydration and structural reconfiguration capabilities have the potential to enhance the internal molecular strength of the hydrogel ,9. NeverPueraria lobata) starch [There has been a recent focus on starch, an essential polysaccharide found in biopolymer-based hydrogels, due to its biocompatibility, biodegradability, and significant biological functionality ,11. In p) starch , with it) starch . However) starch .Nonetheless, the effects of alcohol-exposure techniques go beyond the mere physical characteristics of the gel. Potential health implications may arise from alterations in starch digestibility, specifically in relation to blood glucose levels, glycemic response, gut health, and weight management . TherefoKudzu roots was procured from Xi’an Nature Choice Co., Ltd. . Ethanol, hydrochloric acid (HCl), and sodium hydroxide (NaOH) were also obtained from Sinopharm Chemical Reagent Co., Ltd. . Salivary amylase, Pancreatic α-amylase, and 3,5-dinitrosalicylic acid (DNS) were also supplied by Sigma-Aldrich . All other chemicals were of analytical grade with >99% purity.w/v) starch suspension was prepared from the extracted starch and gelatinized at 90 °C for 30 min, with regular stirring. The resultant gel was poured into a 10.0 mL cylindrical mold and allowed to set at room temperature. Subsequently, the gels were immersed in ethanol solutions of varying concentrations . The set-up of gel immersed in alcohol solution was allowed to stand at room temperature over varying periods of 2, 4, and 6 h for each concentration. For comparison, a control sample was prepared with the same gelling approach without ethanol exposure but kept at 4 °C for 12 h. After the designated periods, samples were appropriately removed and kept for further analysis.Kudzu starch was extracted from the roots following a conventional starch extraction method . A 25%  using Equation (1). The color of gels was also assessed following the method used by Ekumah et al. [L*), redness (a*) and yellowness (b*) of the samples) were measured using the HunterLab ColorQuest XE Spectrophotometer .Sample gels after ethanol exposure were stored at 4 °C for 24 h, thawed, and centrifuged at 5000× h et al. . The C.Ip 0.5) after calibrating it with a 1 kg load. The test speed and compression strain were set at 1 mm/s and 75%, respectively. The hardness (g), springiness, chewiness, and resilience data were then recorded [The determination of the mechanical properties of the gels were achieved using a texture profile analyzer  equipped with a 0.5 inch probe (recorded .−1. Measurements were taken for the elastic modulus (G′), viscous modulus (G″), and loss tangent (Tan δ) based on the angular frequency (ω) spanning from 0.1 to 100 rad/s, ensuring a 2% strain within the linear viscoelastic domain. Modeling of the rheological properties was achieved by fitting the curve to the power model, Equation (2) [The starch gel’s rheological characteristics were evaluated using a DHR-1 rotation rheometer , equipped with a 40 mm diameter parallel plate and a gap of 1.0 mm. The apparent viscosity was studied across a shear rate ranging from 0 to 300 stion (2) .(2)ɳ=KγK, n, and γ denote viscosity (mPa.s), flow consistency coefficient, flow behavior index, and shear rate (s−1), respectively.From the model, ɳ, The morphological characteristics and microstructure of starch gels were evaluated using scanning electron microscopy (SEM) according to Ahmad et al. . Freeze-The X-ray diffractometer  at 40 kV and 30 mA with Cu-Ka radiations was used to determine the crystallographic structural characteristics of the starch gel samples. The X-ray diffraction profile was obtained for 2θ from 5° to 40° with a step size of 0.02/min. The Origin software  integrated the amorphous and crystalline areas, while the relative crystallinity was estimated from Equation (3) as described by Zhang et al. [−1. The spectra ranging from 4000 to 400 cm−1 were recorded three times for each sample in transmission mode and evaluated by Origin software .The chemical and structural configuration of sample starch gels was evaluated using attenuated total reflectance–Fourier transform infrared spectroscopy (ATR-FTIR)  following procedures reported by Wu et al. . In summThe thermal properties of the starch gels were determined by differential scanning calorimetry (DSC) using a differential scanning calorimeter  as per the method described by Ahmad et al. . A samplv/v). The pH was adjusted to 3.0 with HCl (1.0 M) and incubated at 37 °C for 2 h with agitation. Furthermore, the chyme from the gastric digestion was mixed with an equal volume (1:1 v/v) of SIF preheated at 37 °C. The pH was adjusted to 7.0 by adding NaOH (1.0 M). Bile salt (10 mM) was added, followed by pancreatic alpha-amylase (200 U/mL). The set-up was incubated for 2 h at 37 °C in a shaking incubator. Finally, the digested product was centrifuged at 14,000× g for 15 min to collect the transparent supernatant for DNS analysis, to determine the digestible, as well as the pellet for the determination of resistant starch proportion of the gels.The in vitro digestion of starch gels was achieved following the INFOGEST static in vitro simulated gastrointestinal digestion method . Brieflyp < 0.05. Pearson’s correlation analysis was also used to find the correlation between the factors evaluated. All the analyses and graphs were achieved using Origin .All samples were analyzed in triplicate, and the results were presented as means and standard deviations. A one-way analysis of variance (ANOVA) was used to compare means while Tukey test was used to study the significant differences between the mean values at The control exhibited the lowest values for all measured parameters, as shown in Furthermore, the patterns displayed in resilience closely mirrored those seen in springiness, possibly due to their interconnectivity supported by a positive correlation (r = 0.795). From the control 61.31), the value peaked at 91.15 with 100% ethanol for 6 h, indicating superior energy dissipation in ethanol-treated gels as observed in a similar study by Sun et al. . With th1.31, theo, Tp, Tc) and gelatinization enthalpy (ΔHg) as ethanol concentration and exposure time changed. This implies that the interaction of intrinsic factors, such as slight variations in crystallinity  was 45.32 °C, peak temperature (Tp) was 53.92 °C, and conclusion temperature (Tc) was 66.92 °C. This finding corroborates the findings of Sun et al. [c-To narrowed; notably, the 100% ethanol sample at 6 h (16.53–53.53°C) was 6.52 °C, the smallest value recorded, indicating that the thermal transition became quicker as ethanol concentration increased. This observation may indicate a heightened rate of thermal transition at elevated ethanol concentrations. The aforementioned attribute is highly sought after in the industrial sector, as it serves as a crucial factor in determining the level of energy utilized during the ethanol-based kudzu gel processing [For control samples (0% ethanol), the onset temperature  varied with changes in ethanol concentration and exposure time. The highest ΔHg was observed for 100% ethanol concentration at 2 h (2.97 J/g). This could be attributed to the improved cohesion and internal strength conferred on the gel with ethanol exposure irrespective of the exposure time ,6. This Gel production that deviates from the traditional production route towards improving its quality characteristics has the potential to affect the syneresis, gel size, color, and general appearance. As presented in 3) decreased as ethanol concentration increased. Within 2 h, gel size shrank from 8.0 cm3 in controls to 6.3 cm3 at 100% ethanol. By 6 h, it compressed further to 6.2 cm3. Ethanol’s solvent nature possibly reconfigured the gel network, causing this shrinkage. This aligns with prior research demonstrating solvents’ effects on gel structures [L*’ value decreased with rising ethanol levels, suggesting darkening gels. For instance, the control had ‘L*’ value of 65.4 drops to 53.1 at 100% ethanol. Both ‘a’ and ‘b’ values fluctuated: the ‘a*’ value increased to 5.6, and ‘b*’ peaked at 7.3 at 80% ethanol, denoting shifts in color. Such color variations could be due to ethanol’s interaction with the gel matrix, a phenomenon seen in food gels [b*’ and syneresis (r = 0.653) and between gel size and ‘a*’ (r = 0.545) highlight the intertwined nature of these attributes. The manipulation of ethanol concentration and exposure time has a significant impact on the structural and aesthetic characteristics of gels, thereby offering a promising opportunity for optimizing gels in industrial applications.In ructures ,29,30. Iood gels . Correla2 > 0.95 for all samples. This could suggest that models could be use in the process optimization and consistent production of mechanically stable kudzu starch gels. Furthermore, the rheological characteristics, particularly related to the viscoelasticity of the kudzu starch gels, reveal their structural and functional dynamics under varied ethanol conditions [The rheological data presented in nditions ,28. NeveExamining the relationship between the storage modulus (G′) and the loss modulus (G′′) reveals their crucial distinction. A consistent G′ greater than G′′ throughout the experimental angular frequency indicates the gel’s dominant elastic behavior. Interestingly, the elevation of G′ with increasing ethanol concentration and exposure time suggests that, while ethanol disrupts the gel network , it might simultaneously be inducing a structural reorganization or densification in the gel matrix. This behavior, where G′ rises with solvent concentration or exposure time, has been observed in other polysaccharide systems exposed to different solvents ,28. For The Scanning Electron Microscope (SEM) offers an in-depth visualization of the microstructural changes in materials, including starch gels. When kudzu starch gels were exposed to varying concentrations of ethanol and for increasing time duration, several microstructural alterations were observed. The diffractive peak values are significant for understanding the structural changes in materials when exposed to various conditions relying on their A-, B-, or C-type crystallinity pattern . Here, FThe relative crystallinity  of the s−1 for 2 and 6 h . The phenomenon of time dependence was observed in the fluctuation of wavenumber over time. Specifically, shorter durations were found to be associated with higher wavenumbers, indicating an increase in the amount of bound water present in the starch gels. This increase in bound water content can be attributed to the marginal dehydrating effect caused by prolonged exposure to ethanol. This supports the conclusion drawn by Zhao et al. [−1 while the C-O stretching vibration was shown between 992 and 857 cm−1 of the 4 and 6 h ethanol-exposed gel. These FTIR findings not only reaffirmed the molecular intricacies of kudzu starch gels but also emphasized their robustness post ethanol exposure. The subtle distinction observed in the spectra highlights the need for considering such when designing systems that leverage the unique properties of these gels, especially in food, beverages, and edible nutrient delivery agents.The structural configuration of kudzu starch gels after timed ethanol exposure was characterized by FTIR as presented in  and 6 h A,C and a for 4 h B. This iver time ,41. Agaio et al. , buttresp < 0.05) underscores ethanol’s potency in curbing starch gel digestibility, potentially due to ethanol’s interference with starch molecular structures [The data presented in ructures ,31.The analysis of the residual undigested fraction (resistant starch) results revealed that with rising ethanol concentration comes an increase in the resistant starch. This trend holds true across all time intervals. Typically, the control for a 2 h exposure had a resistant starch level of 1.87%, while the sample at 80% ethanol records 7.92%. The data ranges from the control’s 1.87% at 2 h to a peak of 8.73% with 100% ethanol at 6 h. Drawing parallels with the digestible starch data, it is clear there was an inverse correlation (r = −0.845). The elevated resistant starch in the presence of ethanol might be a result of the immediate recrystallization of amylose, forming structures less accessible to enzymatic action ,32,40. FThe residual resistant starch after 242 min. of oral, gastric, and intestinal digestion suggests relics of nondigestible portions of kudzu starch gels ,35 positc-To with increased ethanol suggests faster thermal transitions. Ethanol reduced syneresis, which corresponded with changes in gel size and color. The starch gels displayed a shear-thinning behavior validated by the power law model, with R2 > 0.95. Furthermore, the higher G′ over G′′ coupled with Tan δ values emphasized the gels’ elasticity, modified slightly by ethanol.Our research highlighted the profound influence of ethanol concentration and exposure time on kudzu starch gels. At the lowest ethanol concentrations, gel strength was still enhanced, attributed to a water–ethanol dehydration mechanism. The decreased TSEM images reveal matrix densification upon ethanol treatment, an essential characteristic for efficient absorption and encapsulation of bioactive constituents. Furthermore, the gels’ crystalline characteristics and FTIR spectra remained largely unchanged post ethanol exposure, indicating the absence of detrimental chemical changes due to ethanol. Digestibility tests revealed a shift from digestible starch to resistant starch, providing potential benefits for gut health, diabetes management, and metabolic syndrome prevention. In conclusion, our results emphasize ethanol’s transformative impact on kudzu starch gel’s mechanical, rheological, and digestibility properties, suggesting opportunities to optimize starch-based products. The enhanced robustness of the ethanol-treated kudzu starch gels aligns well with gel-based desserts, confectionery needs, beverages, and nutritional pharmaceuticals, where a consistent texture is essential.


Dental implantology has witnessed remarkable advancements in recent years, and zirconia has emerged as a prominent biomaterial for dental implant applications. This review explores the multifaceted aspects of zirconia, focusing on its properties, processing methods, biocompatibility, mechanical performance, and clinical applications. Over the past few decades, the most popular choice of material for dental implantology has been titanium which has been found to have the highest success rate of implant treatment. However, recently, it has been observed that zirconia might replace titanium and eventually emerge as one of the gold-standard materials of dental implants. Analysis of biomechanical sciences and biomaterial sciences provides an opportunity for the refinement of design and material notions for surgical implants. However, the most important aspect and prime concern is how tissue at the implant site responds to biomechanical disturbances caused by foreign materials.The literature revealed that zirconia has certain characteristics that make it an excellent material for implants, including biocompatibility and osseointegration which depicts positive soft tissue response with low plaque affinity as well as aesthetics owing to light transmission and color. Additionally, this review discusses the current challenges and prospects of zirconia in dental implantology as well as aims to provide dental professionals and researchers with a comprehensive understanding of zirconia’s potential as a biomaterial in dental implantology. The present overview of available literature intends to highlight and explore the biological characteristics of zirconia for applications in dental implantology. However, research is urgently required to fill in gaps over time for clinical assessments of all zirconia implants, consequently, the implementation of hybrid systems (a titanium screw with a zirconia collar) has recently been suggested. Due to their ability to osseointegrate  and affoable gem . Zirconiable gem . CommercAs an alternative to monolithic titanium implants, osseointegration decreases plaque buildup improving the management of soft tissues and aesthetic concerns . This reSearch methodologyWe conducted a review through PubMed and Google Scholar in August 2022 using keywords such as “Zirconia” (title/abstract), biocompatibility, osseointegration, periointegration, bacterial colonization, and titanium. We additionally explored thoroughly key references from bibliographies of the relevant studies. The search was updated in April 2023. The reviewer monitored and observed the retrieved studies against the inclusion and exclusion criteria based on the title and abstract and then on full texts. For inclusion, both published and unpublished studies in the English language were considered. We excluded studies published in other languages because of resource limitations and full-text articles were unavailable to the reviewer. Figure Impact of zirconia’s surface morphology on bone integration2 surface properties affect implant efficacy and long-term survival. Implant microstructure, surface composition and qualities, and design elements are some of these features [2 nanoparticles are much more biocompatible compared to other nanomaterials including iron oxide, titanium dioxide, and zinc oxide (ZnO). Other investigations have revealed that ZrO2 nanoparticles cause barely any cytotoxic effects, although one of the studies demonstrated modest cytotoxic potential, which is consistent with our findings [2, a conventional nanomaterial with comparable physical and chemical characteristics, as a control group. To monitor osteoblast activity, oxidative stress, and cell shape, as well as the response of osteogenesis, titanium dioxide as well as zirconium dioxide nanoparticles were grown with osteoblastic cell MC3T3-E1 [ZrOfeatures . A biomafeatures . Accordifindings . Some scMC3T3-E1 .Mechanical properties of zirconia implantsZirconia implants have garnered considerable attention in the field of dental implantology due to their unique combination of mechanical strength. Tetragonal zirconia polycrystalline (YTZP) materials along with yttria stabilization have remarkable corrosion resistance along with wear resistance in addition to high flexural strength contrary to other dental ceramics . When thFracture Toughness and Resistance to CrackingThis section defines fracture toughness as well as seeks to elucidate its significance in assessing the ability of zirconia implants to withstand crack propagation. It discusses the critical stress intensity factor as a key parameter for characterizing fracture toughness as zirconia has attained immense popularity in dental implantology due to its excellent mechanical properties and biocompatibility. Various factors influence the fracture toughness of zirconia, including grain size, phase composition, sintering conditions, and surface defects. The review explores the crack resistance mechanisms in zirconia implants, including transformation toughening, grain boundary engineering, and stress-induced phase transformations, as well as how these mechanisms enhance the implant’s ability to resist crack initiation and propagation. In addition to this, surface modifications, such as machining, polishing, and glazing, can influence the fracture toughness and crack resistance of zirconia implants. Clinical implications of fracture toughness and crack resistance in zirconia implants play a significant role in preventing implant failure, improving long-term stability, and reducing the risk of complications through testing and measurement techniques to assess fracture toughness and crack resistance in zirconia biomaterials, including indentation-based methods and standardized testing protocols. Acknowledging the significance of these properties and their modulation through material design and processing is essential for dental professionals and researchers seeking to maximize the clinical performance of zirconia implants .Fatigue Behavior and LongevityThis review delves into the crucial aspects of fatigue behavior and longevity of zirconia implants and explores the principles of fatigue, the factors influencing fatigue resistance, and their impact on the long-term performance of zirconia in implants. Factors influencing fatigue resistance of zirconia include material properties, implant design, surface finish, loading conditions, and the oral environment. The mechanisms underlying fatigue failure in zirconia implants include the role of microcracks, stress concentrations, and cyclic loading-induced phase transformations. Aging and degradation processes can affect the longevity of zirconia implants and the impact of environmental factors, such as temperature as well as humidity, on zirconia’s mechanical properties and fatigue resistance over time, and surface modifications impact fatigue resistance and long-term performance. Fatigue behavior along with the longevity of zirconia implants are crucial for establishing and verifying their sustained success in dental implantology. Dental professionals must recognize the significance of these properties and their modulation through material design, surface modifications, and clinical considerations to maximize long-term performance .Biocompatibility of zirconia implants2O3 into monkey femurs revealed that zirconia is biocompatible with hard tissue when evaluated in vivo [The biocompatibility of zirconia was examined using a variety of in vitro experiments on osteoblasts, fibroblasts, lymphocytes, and monocytes, along with macrophages. Because zirconia has no immunosuppressed cytotoxic effects on osteoblasts, the cells can elaborate the extracellular matrix by synthesizing a wide range of various essential and structural proteins. According to Liagre et al. , zirconi in vivo . The pro in vivo .Zirconia and its periointegrative propertiesBoth bone integration and soft tissue integration are connoted by the concept of periointegration. For an implant to be effective and survive for an extended period, both integrations are equally necessary. Both depend on local as well as systemic factors, including the biomaterial’s physicochemical and structural attributes, the tissue  properties, the placement of implants, and the effectiveness of surgical procedures .Processing methods for zirconia biomaterialsZirconia, a biocompatible ceramic material, has become a prominent choice for dental and medical applications due to its exceptional properties and performance. The success of zirconia biomaterials in various clinical applications largely depends on the manufacturing processes employed . This reConventional and Powder ProcessingConventional powder processing involves transforming raw zirconia powder into a solid, dense structure using a series of steps. These steps may include powder shaping, green machining, sintering, and post-processing. These techniques help control the size, shape, and homogeneity of the zirconia particles, which significantly impacts the final material’s properties .Powder ShapingAfter synthesis, the zirconia powder is shaped into the desired form using uniaxial or isostatic pressing. Uniaxial pressing compacts the powder into a mold with a single direction of pressure, while isostatic pressing applies equal pressure from all directions. The valuable insights of this technique in optimizing zirconia biomaterials for betterment and intensified patient care. Various techniques such as uniaxial pressing, isostatic pressing, and recent advancements and innovative methods such as freeze granulation affect powder density, compaction behavior, and green body formation. This property plays a crucial role in determining the initial properties of zirconia and examines how different shaping techniques influence zirconia properties such as density, homogeneity, and microstructure with their implications for eventual processing steps .Green MachiningThe shaped green bodies undergo machining to achieve precise dimensions and surface finish. Green machining allows the formation of complex geometries and customization for specific dental implant designs. Precision shaping of zirconia green bodies before sintering is taken care of in the green machining procedure and subsequently delves into the methods and tools used in green machining, including CNC milling and grinding, with their advantages in achieving complex implant geometries and tolerances .SinteringSintering is a critical step in conventional processing influencing material density and mechanical properties. The green bodies are heated to a high temperature, which facilitates particle diffusion and neck formation, resulting in densification and enhanced mechanical properties. This section examines conventional and advanced sintering techniques, in conjunction with pressureless sintering, spark plasma sintering, and microwave sintering, along with their effects on zirconia implant properties .Post-processing Following sintering, additional treatments such as polishing, glazing, or surface modifications may be applied to improve aesthetics and optimize the biocompatibility of the material .Innovative computer-aided design and computer-aided manufacturing techniquesAdvancements in computer-aided design and computer-aided manufacturing (CAD/CAM) have revolutionized the fabrication of zirconia biomaterials, providing enhanced precision and efficiency. CAD/CAM technologies have offered precise and patient-specific solutions. They have simultaneously revolutionized implantology with the latest advancements in digital workflows, software, and hardware, highlighting their impression on zirconia implant design, manufacturing, and clinical outcomes. Cumulative case studies and emerging trends have analyzed the transformative role of innovative contemporary CAD/CAM techniques in optimizing zirconia implants for enhanced patient care .Digital ScanningIn CAD/CAM systems, digital scanners create high-resolution 3D models of patients' dental structures, facilitating accurate customizations and implant planning and introducing the advancements in digital impression techniques, intraoral scanners, and their role in capturing precise data for designing zirconia implant restorations which signifies exploring their innovative applications in zirconia biomaterials and substantiate the significance of CAD/CAM techniques in implantology .Computer-Aided DesignCAD software allows dental professionals to design patient-specific zirconia implants and restorations, tailoring them to match the individual’s anatomy and requirements. CAD/CAM techniques expedite and facilitate zirconia’s customization abutments and restorations, optimizing fit and esthetics and highlighting the advantage of patient-specific prosthetics .Computer-Aided ManufacturingThe CAM process utilizes milling or 3D-printing techniques to produce zirconia-based dental components directly from digital designs. Milling machines employ diamond-coated tools to carve out the zirconia blocks, while 3D printing involves layer-by-layer additive manufacturing. Ingenious 3D printing techniques enable the fabrication of zirconia implant components with unprecedented precision. Future directions and challenges outline potential future directions, including artificial intelligence (AI)-driven design, bioprinting, and teledentistry and provocation accompanying with adoption and advancing CAD/CAM technologies in zirconia implantology .High-Speed SinteringAn emerging CAM method, high-speed sintering (HSS) uses a combination of inkjet printing and rapid sintering to produce fully dense zirconia components in significantly reduced timeframes. To revolutionize the manufacturing of zirconia biomaterials for dental implantology for enhanced patient care HSS has emerged as a cutting-edge manufacturing technology . The priConventional SinteringTraditional sintering is typically performed in a high-temperature furnace under controlled conditions to achieve adequate particle bonding and densification. Microwave sintering is an innovative sintering method that utilizes microwave energy to achieve rapid and uniform heating, reducing processing time and energy consumption .Hot Isostatic PressingHot isostatic pressing (HIP) is a post-sintering treatment that involves applying high pressure and temperature to further enhance the material’s density and mechanical properties. HIP enhances the reliability and quality of zirconia implants and its potential for improving patient outcomes to achieve densification and eliminate defects in zirconia materials . HIP-indGlazing and Surface ModificationsApplying glaze or surface treatments to zirconia restorations enhances aesthetics, reduces wear on opposing dentition, and optimizes soft tissue response. For understanding the significance and principles of glazing zirconia surfaces, the composition of glaze materials, firing techniques, and the resulting changes in the implant’s surface properties are important. Surface modifications play a pivotal role in optimizing zirconia biomaterials for dental implantology and significantly influence the roughness and topography of zirconia implants and explores how glazing makes a difference to these surface characteristics and its inference for soft tissue attachment as well as bacterial adhesion. The impact of glazing on zirconia’s biocompatibility plays a pivotal role in promoting osseointegration demonstrating improved bone response .Clinical applications of zirconia in dental implantologyDental implantology has undergone significant advancements, and zirconia has played a pivotal role in revolutionizing restorative dental procedures such as single-tooth zirconia implants which have gained considerable attention for single-tooth replacements due to their excellent biocompatibility, mechanical strength, and aesthetic appeal. Moreover, partial and full arch implant-supported prostheses offer a durable and aesthetically pleasing solution for restoring multiple missing teeth. In addition to this, zirconia abutments and restorations provide an alternative to conventional metal-based restorations and discuss the advantages of zirconia abutments, including reduced soft tissue discoloration and improved gingival health, as well as evaluate their clinical performance .Overcoming challenges in complex casesComplex implant cases, such as limited bone volume and angulated implants, often require advanced solutions such as zirconia implant-supported overdentures which offer a secure and cost-effective treatment option for edentulous patients and explore clinical feasibility, advantages, and limitations of using zirconia for implant-retained overdentures. Complex cases often involve patients with limited bone volume, which needs bone augmentation procedures, explore the challenges of bone augmentation with zirconia implants, and discuss advancements such as guided bone regeneration techniques along with customized implant designs to optimize implant placement in compromised bone conditions.Future perspectives and advancementsAdvancements in zirconia materials, manufacturing techniques, and surface modifications present exciting opportunities for further improving clinical outcomes. This section explores potential future developments and their implications for zirconia’s clinical applications in dental implantology . Recent Complications and challenges with zirconia implantsZirconia implants have demonstrated impressive mechanical strength; however, there is an increased risk of vulnerability to fracture and chipping. Contributing factors of zirconia implant fractures include excessive occlusal forces, inadequate design, and flawed materials. Interaction between zirconia implants and peri-implant soft tissues plays a critical role in implant success . Proper Recent advancements and future perspectivesThe increasing interest in zirconia for dental implantology and its potential to overcome the limitations of traditional materials emphasizes the need for continuous research and advancements to optimize zirconia’s performance in dental implant treatments. Recent advancements in zirconia manufacturing techniques, including HSS and CAD/CAM, have revolutionized the production of zirconia dental implants which have led to increased precision, efficiency, and customized implant designs .Zirconia has undoubtedly revolutionized the dental implantology landscape, offering remarkable mechanical properties, biocompatibility, and aesthetic appeal. This review article emphasizes the importance of understanding zirconia’s properties, processing methods, and clinical applications to make informed decisions in dental implantology. Zirconium oxide has several potential applications in dental crowns, post and core systems, and implants. Numerous in vitro and in vivo tests have shown that the material has a high fracture resistance and is suitable for usage in stress-bearing regions. The properties of the zirconium oxide surface such as an absence of micro gaps between the fixtures and the absence of plaque adhesion to the zirconium oxide restrict microbial infiltration. Zirconia has emerged as a versatile as well as promising biomaterial in dental implantology, offering an exceptionally comprehensive understanding of zirconia’s role in dental implantology, despite the challenges and complications that may arise.


During the past two decades, the incidence of chronic kidney disease (CKD) in children worldwide has steadily increased and, even in children, native arteriovenous fistula (AVF) remains the access of choice. Nevertheless, maintaining a well functioning fistula is limited by central venous occlusion due to the widespread use of central venous access devices before AVF creation.A 10 year old girl with end stage renal failure dialysing through a left brachiocephalic fistula presented with left upper limb and facial swelling. She had previously exhausted the option of ambulatory peritoneal dialysis for recurrent peritonitis. A central venogram showed occlusion at the left subclavian vein, which was not amenable for angioplasty through either an upper limb or femoral approach. Given the precious fistula with concomitant worsening venous hypertension, an ipsilateral axillary vein to external iliac vein bypass was performed. Subsequently, her venous hypertension was significantly resolved. This report is the first in English literature on this surgical bypass in a child with central venous occlusion.Central venous stenosis or occlusion rates are rising due to extensive central venous catheter use in the paediatric population with end stage renal failure. In this report, an ipsilateral axillary vein to external iliac vein bypass was used successfully as a safe temporary option to maintain AVF. Ensuring a high flow fistula pre-operatively and continued antiplatelet post-operatively will allow longer patency of the graft. •Central venous stenosis or occlusion is rising due to the widespread use of central venous catheters in the paediatric population with end stage renal failure.•The central venous catheter is being used widely in children compared with arteriovenous fistula due to technical difficulty limited by small vessel diameter and low arterial flow rates.•Successful use of an axillo-external iliac vein bypass as a safe option to maintain an arteriovenous fistula. A left brachiocephalic fistula (BCF) had been created three years before and had functioned well to date. Her left upper limb swelling had started a year previously, and a conventional venogram confirmed left central vein stenosis . An atteAn ipsilateral axillary vein to external iliac vein bypass using an 8 mm × 60 cm supported polytetrafluoroethylene graft  was performed. The left axillary vein was exposed via an infraclavicular incision and the left external iliac vein via an extraperitoneal approach. The graft was tunnelled inferior to the pectoralis minor at the proximal part into the axilla. Subsequently, it was tunnelled subcutaneously along the midaxillary line and lateral abdomen from the axillary vein to the ipsilateral external iliac vein. The proximal and distal anastomoses were done using an end (graft) to side (native vein) technique. The intra-operative course was uneventful. On the same day, the patient's left upper limb swelling improved immediately. Her dialysis was resumed through the left BCF the next day and she was discharged with a single antiplatelet. In the clinic, her BCF flow rate was 1.8 L/min, the graft flow rate was 1.2 mL/min, and the upper limb swelling had markedly improved B. The paRising ESRF numbers among children highlight the importance of knowledge among clinicians about the existing armamentarium on dialysis access in children. In children requiring renal replacement therapy, renal transplantation is the preferred choice worldwide due to the superior quality of life it offers. However, if pre-emptive transplantation is unavailable, peritoneal dialysis or haemodialysis are potential alternatives. Haemodialysis through an AVF has more advantages than a central venous catheter (CVC) in terms of its greater longevity and lower rate of infection. Despite this, the central venous catheter is being used more widely in children than AVF due to the technical difficulties when limited by small vessel diameter and low arterial flow rates.The complications of a CVC include complete occlusion or stenosis of the central veins. CVC dependence of more than six months is a significant risk factor for developing central vein stenosis or occlusion.Repeated central venoplasty is the intervention of choice in symptomatic cases to relieve obstructive symptoms and also ensure the continued patency of the fistula. A surgical procedure is the next step in patients for whom the endovascular approach has failed. Unfortunately, there are very few publications on managing central venous stenosis in the paediatric population. de Buys Roessingh et al. reported a successful recanalisation of superior vena cava (SVC) stenosis via an endovascular femoral approach in two patients under one year of age.Almost all the evidence of surgical vein–vein bypasses is from adult case series and reports. The available options for a surgical vein–vein bypass include outflow to an ipsilateral unobstructed external or internal jugular vein; contralateral subclavian or internal jugular vein; lower extremity venous outflow, such as the femoral or popliteal vein; and intrathoracic or intra-abdominal vena cava or right atrium. Dammers et al. have reported one year primary patency of 75% among the 10 adult patients with surgical reconstruction for central venous occlusion.A common concern when using any synthetic graft in the paediatric population is the inability of the graft to elongate with the growth spurts of the patient. Growth retardation among children with end stage renal failure is well known; thus, it was decided to proceed with the surgical bypass using a graft. Alternative options, such as a great saphenous vein substituting synthetic graft for a vein–vein bypass, were unacceptable due to the smaller calibre of the conduit, which entails a high probability of thrombosis. However, graft extension bypass is a potential future option if a problem rises due to the child's growth.Maintaining the bypass graft's patency is important while awaiting a definitive treatment such as a renal transplant. Saravanan et al. have reported a few factors to ensure a successful outcome of a vein to vein bypass graft, such as a high pre-operative fistula flow rate (>1500 mL/min), long term antiplatelets, and ensuring a graft flow rate of more than 1000 mL/min during follow up in order to maintain a well functioning graft.In conclusion, central venous stenosis or occlusion rates are rising due to extensive CVC use in the paediatric population with end stage renal failure. This report shows successful use of axillary vein to external iliac vein bypass as a safe option to maintain an AVF in central vein occlusion. Ensuring a high flow fistula pre-operatively and continued antiplatelets post-operatively will ensure the longer patency of the graft.None.None.