Mycobacterium ulcerans and is characterized by skin lesions. Several studies were performed testing the Bacillus Calmette-Guérin (BCG) vaccine in human and animal models and M. ulcerans-specific vaccines in animal models. However, there are currently no clinically accepted vaccines to prevent M. ulcerans infection. The aim of this study was to identify T-cell and B-cell epitopes from the mycobacterial membrane protein large (MmpL) proteins of M. ulcerans. These epitopes were analysed for properties including antigenicity, immunogenicity, non-allergenicity, non-toxicity, population coverage and the potential to induce cytokines. The final 8 CD8+, 12 CD4+ T-cell and 5 B-cell epitopes were antigenic, non-allergenic and non-toxic. The estimated global population coverage of the CD8+ and CD4+ epitopes was 97.71%. These epitopes were used to construct five multi-epitope vaccine constructs with different adjuvants and linker combinations. The constructs underwent further structural analyses and refinement. The constructs were then docked with Toll-like receptors. Three of the successfully docked complexes were structurally analysed. Two of the docked complexes successfully underwent molecular dynamics simulations (MDS) and post-MDS analysis. The complexes generated were found to be stable. However, experimental validation of the complexes is required.Buruli ulcer (BU) is a neglected tropical disease. It is caused by the bacterium  Since the initial use of the term ‘vaccine’ by Edward Jenner in 1796, it has led to the eradication of smallpox, the nearly complete elimination of polio and is estimated to have reduced the cost of illnesses and hospitalizations by more than $500 billion in 94 low- and middle-income countries . Vaccinein silico bioinformatics [Various new technologies used in vaccine research include genomics, transcriptomics, proteomics, metabolomics and immunomics . These ‘ormatics . One sucormatics ,12. Thisormatics . It alsoormatics . For theormatics . This apormatics . HoweverMycobacterium ulcerans [−1 of rifampicin once daily combined with 7.5 mg kg−1 clarithromycin twice daily. Early diagnosis and treatment are critical in minimizing the symptoms of this disease [The causative agent of the neglected tropical disease Buruli ulcer (BU) is ulcerans . Symptomulcerans . Howeverulcerans ,16. Thisulcerans . Previouulcerans . The curulcerans  is the u disease . However disease . Further disease .M. ulcerans-specific vaccines have been carried out in various animal models; however, long-term protection was not observed [M. ulcerans. The first study focused on chromosome-encoded virulence proteins [M. ulcerans [M. ulcerans proteome remain to be studied.Presently, there are no clinically accepted BU vaccines available. The Bacillus Calmette-Guérin (BCG) vaccine used against tuberculosis is the only vaccine tested in humans against BU ,22. Howeobserved –36. The observed ,38. Thesproteins , while tulcerans . The ideulcerans  and vacculcerans  displaye+ and CD4+ T-cell and B-cell epitopes with desirable properties from the MmpL proteins of M. ulcerans. Once screened, these epitopes are used to construct vaccine candidate sequences and docked with Toll-like receptors (TLRs). These constructs and complexes undergo analysis to determine their capability to produce a protective immune response against M. ulcerans infection.One such set of proteins is the mycobacterial membrane protein large (MmpL) proteins. These transporters are a subclass of the resistance-nodulation-cell division (RND) superfamily . The Mmp. 2. 2.1. 2.1.1M. ulcerans genomes were extracted from the National Center for Biotechnology Information database (NCBI) (https://www.ncbi.nlm.nih.gov/) . They were downloaded in protein format and submitted to the MP3: Prediction of Pathogenic/Virulent Proteins database (http://metagenomics.iiserb.ac.in/mp3/index.php), with the threshold set to 0.5 [https://www.ebi.ac.uk/Tools/msa/clustalo/) [https://services.healthtech.dtu.dk/service.php?TMHMM-2.0) [Twelve t to 0.5 . Potentit to 0.5 . Only Mmustalo/) . Once alHMM-2.0) ,45 to id. 2.1.2http://www.allelefrequencies.net/default.asp) [+ and CD4+ epitope peptides, based on the availability of the HLA alleles on the respective websites  [In order to determine the human leucocyte antigen (HLA) alleles to be selected for analysis, the Allele Frequency Net Database (ult.asp)  was usedable S3) –48.. 2.1.3. 2.1.3.1https://services.healthtech.dtu.dk/service.php?NetMHCpan-4.1), with the peptide length set to 9 [50 values ≤ 250 nM were extracted and submitted to VaxiJen v 2.0 (http://www.ddg-pharmfac.net/vaxijen/VaxiJen/VaxiJen.html) for antigenicity analysis [http://tools.iedb.org/immunogenicity/) [The identified potential outer membrane proteins were extracted and submitted to the NetMHCpan v 4.1 website  to predict which peptides would be capable of binding to MHC II molecules of known sequences [50 values ≤ 250 nM were extracted. These peptides underwent antigenicity analysis using VaxiJen v 2.0 (http://www.ddg-pharmfac.net/vaxijen/VaxiJen/VaxiJen.html) [The identified potential outer membrane proteins were also submitted to NetMHCIIpan v 4.0 (equences . The ideen.html) . The tar. 2.1.4+ epitopes were submitted to the IFNepitope Web server (http://crdd.osdd.net/raghava/ifnepitope/predict.php) [https://webs.iiitd.edu.in/raghava/il4pred/predict.php) [+ and cytokine-inducing CD4+ epitopes were submitted to AllerTOP v. 2.0 Web server (https://www.ddg-pharmfac.net/AllerTOP/) [https://webs.iiitd.edu.in/raghava/toxinpred/index.html) [http://tools.iedb.org/conservancy/) [+ epitopes with 100% linear conservancy were identified and used to identify overlapping CD4+ epitopes. Due to the large quantity of T-cell epitopes, conserved epitopes with an antigenicity score ≥ 1.5 were selected. Conservancy analysis (http://tools.iedb.org/conservancy/) and identification of CD4+ T-cell epitopes were performed on the filtered epitopes [The identified antigenic CD4ict.php) . Epitopeict.php) . The crilerTOP/) . This waex.html) ,55 for trvancy/) . CD8+ epepitopes . The sou. 2.1.5http://tools.iedb.org/population/) [+ and 12 CD4+ T-cell epitopes and their respective HLA alleles were inputted . The endemic regions were chosen per the WHO database [The conserved T-cell epitopes were submitted to the Population Coverage Web server (lation/) . The 8 Cdatabase . The fol. 2.1.6https://webs.iiitd.edu.in/raghava/abcpred/index.html) to identify potential B-cell epitopes [http://www.ddg-pharmfac.net/vaxijen/VaxiJen/VaxiJen.html) [http://tools.iedb.org/conservancy/) [+ epitopes. CD8+ epitopes with a conservancy of 100% were selected and used to identify overlapping B-cell epitopes. The conserved B-cell epitopes were submitted to AllerTOP (https://www.ddg-pharmfac.net/AllerTOP/) for allergenicity analysis and ToxinPred (https://webs.iiitd.edu.in/raghava/toxinpred/index.html) for toxicity analysis [The initially identified outer membrane peptides were submitted to ABCpred   for antirvancy/)  along wianalysis –55. A to. 2.1.7+ T-cell epitopes were HLA-A*23:01, HLA-A*24:02, HLA-C*24:06 and HLA-C*24:13. HLA-A*24:02 was chosen, and the corresponding crystalline structure 5WWJ [https://www.rcsb.org/) [+ T-cell epitopes was HLA-DRB1*15:01. The crystalline structure 5V4M [https://www.rcsb.org/) [http://www.attract.ph.tum.de/services/ATTRACT/peptide.html) for docking analysis. The docking was completed on the locally installed ATTRACT on the Centre for High-Performance Computing (CHPC) South Africa. Upon completion of docking, there were 50 frames generated for each docking interaction for the T-cell epitopes. The frame with the lowest binding energy was selected for the CD8+ and CD4+ T-cell epitopes. Visual Molecular Dynamics (VMD) software v 1.9.3 was used to visualize the best model for each epitope, and UCSF Chimera v.1.14 was used to produce images of the epitope structures [+ v. 2.2.5 was used to generate a ligplot for the CD8+ T-cell epitope with the lowest binding energy [+ T-cell epitope with the lowest binding energy and the respective HLA allele [The molecular docking of the conserved T-cell epitopes to their respective HLA alleles was performed to observe possible interactions between the epitopes and the respective MHCs . The mosure 5WWJ  was downsb.org/) ,64. The ure 5V4M ,66 was asb.org/) ,64. Bothsb.org/) . Preparasb.org/)  was usedructures ,69. LigPg energy . The BIOA allele .. 2.2. 2.2.1+ and 12 CD4+ T-cell and 5 B-cell epitopes. These epitopes were used to construct 5 candidate vaccine sequences. The adjuvants chosen consisted of human β-defensin 2 (hBD2), and the TLR 2 and 4 agonists lipoprotein LprG [https://www.ncbi.nlm.nih.gov/). Various linkers were used between the adjuvant, CD8+, CD4+ T-cell epitopes and the B-cell epitopes . The epitopes were ordered per decreasing antigenicity value. The 5 models were submitted to AllerTOP v. 2.0 (https://www.ddg-pharmfac.net/AllerTOP/) [http://www.ddg-pharmfac.net/vaxijen/VaxiJen/VaxiJen.html) [The final number of epitopes consisted of 8 CD8ein LprG  and the ein LprG . These alerTOP/)  and Vaxien.html) , with th. 2.2.2https://npsa-prabi.ibcp.fr/cgi-bin/npsa_automat.pl?page=/NPSA/npsa_gor4.html) to predict the secondary structures [https://galaxy.seoklab.org/cgi-bin/submit.cgi?type=TBM) [https://galaxy.seoklab.org/cgi-bin/submit.cgi?type=REFINE) [https://prosa.services.came.sbg.ac.at/prosa.php) for validation [https://saves.mbi.ucla.edu/) [The constructs were submitted to the Gor IV Secondary Structure Prediction Method Web server  –80 for s=REFINE) ,82 for flidation ,84. Furtla.edu/) –87.. 2.2.3https://web.expasy.org/protparam/) [in silico physical and chemical properties. These properties consist of molecular weight, amino acid composition, isoelectric point, instability index, aliphatic index, the grand average of hydropathicity (GRAVY) and the estimated half-life of the protein in mammalian cells, yeast cells, and Escherichia coli [http://babylone.ulb.ac.be/SCooP/index.php) [Tm), change in enthalpy (ΔHm), change in specific heat upon folding (ΔCp), and the folding free energy at room temperature (ΔGr), are determined by this website [The candidate sequences were submitted to the ProtParam tool (tparam/)  for analhia coli . The moddex.php) –91. Vari website –91.. 2.2.4http://www.jcat.de/) [Escherichia coli (strain K12) was selected as the model organism. This organism was selected due to the dissimilarity between its codon usage and humans, which may result in higher expression [https://www.snapgene.com/).The JAVA Codon Adaption Tool (JCat) (cat.de/)  was usedpression . The res. 2.2.5https://www.rcsb.org/), respectively [The crystalline structures for TLR2 (3A7B) ,95 and Tectively ,64. UCSFectively . The strectively . However. 2.2.6http://biocomp.chem.uw.edu.pl/CABSflex2) [https://www.ebi.ac.uk/thornton-srv/databases/profunc/) [http://212.87.3.12/A3D2/) [The CABSflex v. 2.0 website (BSflex2)  was usedrofunc/)  and viewrofunc/) . AGGRESC2/A3D2/)  was used. 2.2.7https://kraken.iac.rm.cnr.it/C-IMMSIM/index.php?page=1) was used to simulate potential immune responses to MEV1, MEV2 and MEV5 [C-IMMSIM  simulation. The complexes were equilibrated at 300 K for an additional 2 ns at a pressure of 1 bar. The production stage was run for 100 ns at NVT. The simulations were run using the GPU (CUDA) version of PMEMD provided in AMBER 18 [Molecular dynamics simulations (MDS) using the AMBER 14 and 18 packages were performed on the docked complexes, bound, and unbound MEV constructs ,105. MDSs of 8 Å . InitialAMBER 18 –111.. 2.4Post-MDS analysis was performed using the CPPTRAJ and PTRAJ modules in AMBER 18 ,112. TheThe CPPTRAJ and PTRAJ modules generated 2000 frames of the complexes and the unbound MEVs . VMD v 1. 3. 3.1. 3.1.1A total of 49 potentially virulent MmpL proteins were identified. Following alignment, there were 465 peptides with varying lengths. There were 237 peptides that were determined to have an outer topology.. 3.1.2+ T-cell and 2040 CD4+ T-cell epitopes identified to be MHC I and II binders, respectively. Following antigenicity and immunogenicity analysis of the CD8+ T-cell epitopes, 464 and 321 epitopes were identified, respectively. There were 806 antigenic CD4+ T-cell epitopes, of which 259 were capable of potentially inducing IFN-γ and 128 were capable of potentially inducing IL-4. A total of 236 CD8+ and 84 CD4+ T-cell epitopes were determined to be non-allergenic and non-toxins. There were 36 conserved CD8+ T-cell epitopes, which overlapped with 46 CD4+ T-cell epitopes. Upon completion of the filtration of T-cell epitopes, there were 11 CD8+ and 13 CD4+ T-cell epitopes. There were 8 conserved CD8+ and 12 overlapping CD4+ T-cell epitopes . The antigenicity scores of the CD8+ epitopes ranged from 3.89 (WFWWSPPPF) to 1.80 (RVRTRPTRT), and those of the CD4+ epitopes ranged from 2.21 (WFWWPMRVRTRPTRT) to 1.54 (FWWPMRVRTRPTRTP) . The highest IC50 score for the CD8+ epitopes was 231.45 (RWFWWPMRV), and the lowest was 17.01 (WFWWPMRVR). The IC50 scores of the CD4+ epitopes ranged from 249.13 (LLGRWFWWPLRVRSR) to 20.00 (RWFWWPMRVRTRPTR). The identified CD8+ and CD4+ T-cell epitopes were traced back to 11 potentially virulent MmpL proteins, of which there was an overlap of proteins between the CD8+ and CD4+ epitopes .There were 1127 CD8. 3.1.3a). From 43 through to 60 epitope hits/HLA combinations, the number of individuals was 0 (a). The global class I, class II and class combined population coverages were 49.96%, 95.43% and 97.71%, respectively . All the global estimates were above the estimated average . Papua New Guinea had the highest class combined population coverage (99.90%), while Liberia had the lowest (28.23%) .The highest number of epitope hits or HLA combinations recognized by the highest percentage of individuals was 5 (7.50%), and the lowest, excluding 0, were 40 to 42 (0.01%) a. From 4ls was 0 a. The gl. 3.1.4A total of 334 B-cell epitopes were identified by ABCpred. These epitopes were then screened for antigenicity and reduced to 138 B-cell epitopes. There were 93 non-allergenic and non-toxic epitopes. Upon completion of conservancy analysis, 5 overlapping B-cell epitopes were identified . The antigenicity scores of the epitopes ranged from 2.06 (WFWWPMRVRTRPTRTP) to 1.28 (MTPAIAALLGRWFWWP) . The highest ABCpred score was 0.92 (MMPAIAALLGRWFWWP and MTPAIAALLGRWFWWP), and the lowest was 0.82 (LGRWFWWSPPPFLRAS). The B-cell epitopes were traced back and found to originate from 11 potential virulent proteins . The virulence scores of the source proteins of the T- and B-cell epitopes ranged from 0.50 (WP_157759966.1) to 1.10 (WP_240273203.1) .. 3.1.5+ T-cell epitopes were successfully bound to the most conserved HLA allele (a). The binding energies of the CD8+ epitopes to HLA-A*24:02 ranged from −187.81 kcal mol−1 (RWFWWPLRM) to −112.00 kcal mol−1 (WFWWPLRVR) (b). The CD4+ T-cell epitopes were also successfully bound to the most conserved HLA allele (c). The binding energies of the CD4+ epitopes to HLA-DRB1*15:01 ranged from −126.59 (ALLGRWFWWPLRMPT) to −179.55 (RWFWWPMRVRTRPTR) (d).The identified CD8A allele a. The biWWPLRVR) . The resWWPLRVR) b. The CDA allele c. The biVRTRPTR) . The hydVRTRPTR) d.Figure. 3.2. 3.2.1Five vaccine sequences were constructed, as shown in . 3.2.2in vitro), yeast (in vivo) and E. coli (in vivo) were 30 h, greater than 20 h and greater than 10 h, respectively. Gibbs–Helmholtz curves were generated based on the five vaccine candidate structures . MEV4 had the highest melting temperature (65.00°C), while MEV3 had the lowest melting temperature (52.70°C) . Only MEV2 had negative values for ΔHm, ΔCp and ΔGr, as indicated by the difference in the curve .The vaccine sequences consisted of varying numbers of amino acids . All the. 3.2.3in silico into the pET-28a(+) plasmid (The codon adaptation index (CAI) value for all the vaccine candidate sequences was 1. The GC content was 60.89 (MEV1), 63.71 (MEV2), 62.77 (MEV3), 61.65 (MEV4) and 60.03 (MEV5). The sequences were cloned  plasmid . The len plasmid .Figure . 3.2.4a). The minimal, maximal, average, and total scores of complex 2 were −3.59, 3.25, −0.47, and −585.18, respectively (figure 7b). Complex 3 had a minimal score of −3.70, a maximal score of 5.35, an average score of −0.31, and a total score of −331.19 (figure 7c). Complex 1 had the highest number of soluble residues, while complex 3 had the lowest  were successfully docked to their respective TLR, resulting in complex 1, complex 2 and complex 3, respectively . The besfigure 7e lowest . Complexe lowest .Figure . 3.2.5a and 9a; electronic supplementary material, figure S8A). However, only MEV2 induced IgG1 + IgG2 and IgG2 and had the highest levels of IgM + IgG and IgM . For all vaccine candidates, the antigen response increased and consequentially decreased within the 0 to 5-day period . All vaccine sequences induced the production of memory, non-memory, and B isotype IgM B-cells . MEV2 generated the lowest number of B isotype IgM and memory B-cells (b). The production of B isotype IgG1 and IgG2 was negligible . The population of memory CD8+ T-cells remained constant throughout the simulation for all the sequences . The induction of non-memory CD8+ T-cells fluctuated throughout the simulation, and the values were similar . All the sequences induced the production of memory and non-memory CD4+ T-cells; however, MEV5 induced the lowest number of both types of cells . The vaccine sequences induced the production of IFN-γ, transforming growth factor beta (TGF-β), IL-2, IL-10, and IL-18 . The levels of IFN-γ and IL-18 induced were similar for all the sequences; however, MEV5 induced the lowest amount of IL-10 and TGF-β .Immune simulations were carried out for MEV1, MEV2, and MEV5 (figures 8 B-cells b. The pr. 3.3a). However, there was an overlap of the RMSD values of the bound and unbound for the third complex (b). The fluctuations of the backbone of the atoms of the bound MEV1 ranged from 0.55 Å to 16.09 Å, while the fluctuations of the backbone of the atoms of the unbound MEV1 ranged from 0.55 Å to 27.75 Å (a). The highest value for the fluctuations of the backbone of the atoms for the bound MEV5 was 0.49 Å, and the lowest was 22.74 Å (b). The fluctuations of the backbone of the atoms of the unbound MEV5 ranged from 0.52 Å to 24 Å (23.9954) (b). These values indicate better stability of the bound MEVs. Residues within the third complex displayed lower fluctuations than the first complex . There was also an overlap between complex one and the unbound MEV1 (c).The RMSD values of complex one and the bound MEV were lower than that of the unbound MEV a. Howeve complex b. The fl 27.75 Å a. The hi 22.74 Å b. The fl23.9954) b. These  complex c,d. Therund MEV1 c.Figure. 3.4a). PC1 to PC3 contributed 76% of the total proportion of the variance shown in the eigenvalue plot (figure 11a). The greatest contribution was by PC1 (52.61%), followed by PC2 (15.99%) and then PC3 (7.40%) (figure 11a). This differed from the principal cross-correlation captured for complex one, which was 92.10 . The total contributions of PC1 to PC3 were estimated to be 72.68% . PC1 contributed 51.77%, PC2 contributed 16.09%, and PC3 contributed 4.82% . The fifth vaccine sequence had a lower proportion of variance than the first, i.e. 93.80% (figure 11b). The three PCs were accountable for 71.91% (figure 11b). PC1 contributed the highest variability, followed by PC2 and PC3, with proportions of 48.93%, 16.28% and 6.70%, respectively (figure 11b). The variance of the third complex was lower, with the 20 PCs capturing 89% of the variance . PC1 to PC3 contributed 64.47% of the variance . Similar to the other plots, PC1 contributed the highest (48.08%), then PC2 (12.98%), and PC3 (6.41%). Residues within the complexes and vaccine constructs were observed to move in similar directions near the diagonal, indicating the inter-correlation of residues  function, which facilitates the differentiation of CD4+ T-cells to Th1 or Th17 [The epitopes that displayed the abovementioned desirable properties were combined, together with linkers and adjuvants, to form several vaccine candidate sequences. The addition of the adjuvants was done to increase the stimulation of the immune response, thereby increasing the immunogenicity of the vaccine construct ,125. TLRet al.  found thrculosis . RpfE wa or Th17 . hBD2 wa or Th17 . Defensi or Th17 . Linkers or Th17 . The EAA or Th17 . It is a or Th17 . The AAY or Th17 . This wa or Th17 . The KK  or Th17 . Linkers or Th17 . Some ofin vitro conditions also impact the stability of a protein [The vaccine constructs displayed several physico-chemical properties. Proteins with molecular weights ≤110 kDa are desirable in vaccine development due to rapid purification ,136. All protein . Stabili protein . The estE. coli (strain K12) [M. ulcerans-specific candidates in animal models have observed the induction of specific immunoglobins, such as IgG, IgG1, IgG2a and IgG2b [M. ulcerans infection [M. ulcerans infection in this model [The CAI is used to measure codon usage bias, with it correlating positively to gene expression . The higain K12) . The GC ain K12) . The simnd IgG2b ,32,34,36nd IgG2b . High lend IgG2b . IgG pronfection . It was is model . The proβ-sheets [The secondary structures of proteins impact protein folding and provide information regarding the functions and interactions of the protein . The larβ-sheets . These sβ-sheets . This waβ-sheets . The lowM. tuberculosis; this includes the induction of apoptosis and anti-inflammatory responses in macrophages [TLRs are crucial in recognizing pathogenic signals and activating innate and adaptive immune responses . Throughrophages ,156.The bonds within the TLR–vaccine complexes consisted mainly of hydrogen bonds and salt bridges. Both of these types of interactions are involved in protein binding . The prein vitro and ex vivo studies is required [MDS was used to further analyse the interactions between the proteins and ligands and the conformational modification of the proteins at the atomic level . The RMSrequired ,166. MMGrequired . In thisrequired . These irequired . Hydrogerequired ,160. ThiM. ulcerans infection. This study serves to further the scope of existing screened epitopes. However, further experimental validation is required as this work was only done computationally.BU remains a burden on not only affected individuals but communities as a whole. Early diagnosis and treatment prevent the development of severe symptoms. The prevention or control of the infection may also be beneficial. However, control and prevention methods remain lacking. The epitopes, and by extension, the vaccine constructs and complexes generated in this study displayed several appropriate characteristics. These characteristics suggest the ability of these constructs to generate a potentially protective immune response against


However, this is achieved at the expense of an increase in clinically important bleeding, underscoring the importance of balancing thrombotic risk and bleeding risk when considering antithrombotic therapy after CABG. In contrast, anticoagulant therapy has proved ineffective at reducing the occurrence of graft thrombosis, pointing to platelet aggregation as the key driver of graft thrombosis. We provide a comprehensive review of current practice for prevention of graft thrombosis and discuss potential future concepts for antithrombotic therapy including P2Y12 inhibitor monotherapy and short-term DAPT.Coronary artery bypass grafting (CABG) is the most frequently performed cardiac surgery worldwide. The reported incidence of graft failure ranges between 10% and 50%, depending upon the type of conduit used. Thrombosis is the predominant mechanism of early graft failure, occurring in both arterial and vein grafts. Significant advances have been made in the field of antithrombotic therapy since the introduction of aspirin, which is regarded as the cornerstone of antithrombotic therapy for prevention of graft thrombosis. Convincing evidence now exists that dual antiplatelet therapy (DAPT), consisting of aspirin and a potent oral P2Y Coronary artery bypass grafting (CABG) is the most frequently performed cardiac surgery worldwide, and over 300,000 procedures are performed in the United States alone per year . The repGrafts used for CABG are either arterial grafts that are typically harvested from the chest wall [internal thoracic arteries (ITA)], arms [radial artery (RA)], and abdomen [right gastroepiploic (RGEA)], or vein grafts harvested from the lower extremities (saphenous veins). Despite lower patency rates compared to arterial grafts, vein grafts remain the most frequently used graft in CABG, with a usage rate that approaches 90% globally .Graft failure represents complete occlusion of the graft preventing blood flow to the portion of the heart targeted for revascularization. Morphological and functional characteristics of the graft, as well as the target vessel , technical factors , and underlying patient-related atherosclerotic risk contribute to the multifactorial process of graft failure.The dominant mechanism of graft failure varies by type of graft and with time from surgery. Early graft failure, or graft occlusion occurring within the first month after CABG, is characterized by acute thrombosis, and its prevention is the target of antithrombotic medications after CABG. Both arterial and vein grafts may fail due to acute thrombosis; however, thrombotic graft occlusion occurs more frequently in the latter. Vein graft failure occurring beyond the first month after CABG is characterized by intimal hyperplasia and accelerated atherosclerosis  6, 8, 9, 98, 9. The initial injury underlying the process leading to acute graft thrombosis is that to the vascular endothelium. Disruption of endothelial integrity is typically incurred during graft harvesting due to mechanical trauma, and, although also described in free arterial grafts , is predEndothelial injury leads to activation of a platelet-mediated thrombotic cascade  5). Pro. Pro5). 2 synthesis, thus inhibiting platelet aggregation (P = 0.012) (P < 0.05) (P < 0.0001), with the best time for aspirin initiation being within six hours of surgery  vs. once-daily administration of high-dose aspirin (200–325 mg) showed that more frequent dosing was more effective in suppressing serum TXB2 formation  . In the = 0.012) . All asp < 0.05) . A 1993  surgery . A meta- aspirin 0–325 mg ormation , which hormation . HoweverThere are currently discrepant recommendations for timing and dosing of aspirin after CABG. The 2021 American College of Cardiology (ACC)/American Heart Association (AHA)/and Society for Cardiovascular Angiography and Interventions (SCAI) Guideline for Coronary Artery Revascularization recommends 100–325 mg aspirin daily initiated within six hours postoperatively and then continued indefinitely to reduce the occurrence of vein graft closure and adverse cardiovascular events  . The 20112 receptor inhibitors inhibit binding of adenosine diphosphate (ADP) to its platelet P2Y12 receptor, preventing the ADP-mediated activation of the GPIIb/IIIa complex and subsequent platelet aggregation ] leads to enhanced platelet inhibitory effects  or vein graft patency  one year after CABG (P = 0.04) (P = 0.02), and with an increased risk of major bleeding events  (The study design of CABG RCTs of DAPT vs. aspirin that included protocol-defined graft imaging are presented in ter CABG . In the  = 0.04) . In a 20 = 0.05) . A subgr = 0.05)  comparinP < 0.001). The trial was performed in an exclusively Chinese population, and 75.8% of patients underwent off-pump CABG, thus limiting generalizability of the findings. In the POPular-CABG trial (P = 0.64). However, the trial was limited by poor compliance with the allocated treatment, as 37.8% of patients in the ticagrelor arm permanently discontinued the study medication during the 12 months of treatment.The two larger RCTs investigating the effect of ticagrelor (90 mg twice daily) plus aspirin (80–100 mg once daily) with aspirin alone have yielded conflicting results , 40. TheP < 0.01), but major bleeding events were significantly increased . A network meta-analysis (P < 0.001) and this finding was consistent across all prespecified subgroups, including those undergoing off-pump CABG (P < 0.001), and the finding was consistent when stratified by arterial  vs. vein grafts  (pint = 0.93). Notably, the median treatment duration with ticagrelor DAPT was one year, and ticagrelor DAPT was associated with an increased risk of clinically important bleeding events compared with aspirin alone .A meta-analysis of 22 studies and 20,315 patients by Cardoso et al.  comparinanalysis  of 20 RCump CABG . TicagreIn the only placebo-controlled RCT testing a DAPT strategy including prasugrel vs. aspirin Danek et al. reported no difference in the incidence of optical coherence tomography-detected vein graft thrombus in 84 patients one year after CABG .The 2021 ACC/AHA/SCAI guidelines give a COR IIb, LOE B-R  recommen12 inhibitor monotherapy after CABG, and are summarized in P = 0.77; vein graft: 98.1% vs. 98.2%; P = 0.73) or one year after CABG   .P = 0.10). The TARGET trial randomizing 250 patients after CABG to ticagrelor monotherapy (90 mg twice daily) or aspirin (81 mg twice daily) similarly found no difference between groups in the incidence of vein graft occlusion at one year  (P = 0.28) or the secondary safety endpoint of major bleeding ; however, this study did not include graft failure as an outcome  . The TiC outcome .P = 0.45; rivaroxaban alone vs. aspirin: 7.8% vs. 8.0%; OR: 0.95, 95% CI: 0.67–1.33; P = 0.75). This points to graft thrombosis as a primarily platelet-driven event, and antithrombotic strategies including oral anticoagulants are currently not recommended for prevention of graft failure.While phenprocoumon improved graft patency vs. placebo in a 1981 RCT of 89 patients eight weeks after CABG , subsequThe association between graft failure and clinical events is complex, and may vary by type of graft and the area of subtended myocardium supplied by the failed graft . StudiesWomen and racial minorities are underrepresented in cardiovascular RCTs –59, and With an ageing population and rising life expectancy, an increasing proportion of patients undergoing CABG are elderly adults. A higher prevalence of comorbidities and age-related changes in drug metabolism place elderly patients at a higher risk of ischemic events as well as bleeding events . The pre12 inhibitor monotherapy may represent a potential alternative for intensified platelet inhibition without added bleeding risk. In the setting of PCI, shortening the duration of DAPT has become the focus of many studies to reduce bleeding risk while preserving ischemic efficacy. Considering that thrombosis is the predominant mechanism of early graft occlusion and typically occurs during the first month after surgery, DAPT in the setting of CABG may prove most beneficial when given short-term, followed by aspirin alone  after a certain period to mitigate the long-term bleeding risk associated with DAPT. An antithrombotic strategy of short-term DAPT after CABG will necessitate evaluation in adequately powered RCTs.Although ticagrelor monotherapy was not associated with a significant difference in the incidence of vein graft failure compared with aspirin in a recent meta-analysis, the direction of the treatment effect pointed to a potential benefit of ticagrelor monotherapy . As tica


Arquivos Brasileiros de Endocrinologia e Metabologia, first published 70 years ago. That's also my seventh year as Editor-in-Chief. During this period, the AE&M, official scientific journal of The Brazilian Society of Endocrinology and Metabolism (SBEM), increased its impact factor from 0.6 to 2.309 . In 2020 the numbers went to: 190 (33%) vs. 387 (67%). Also, the amount of countries increased significantly encompassing all world continents. This improvement could not be achieved without the collaboration of our Associated Editors, Reviewers from Brazil and abroad, editorial assistants, and the support of SBEM's board of Directors.The number of submitted papers from outside Brazil also increased. In fact, in 2015 the Journal received 165 Brazilian manuscripts and 191 from other countries (46.3% Recently our site was renewed, becoming more attractive and interactive. Therefore, I will begin my eighth year as Editor aiming to continuously improve AE&M and project it more and more in the international scientific scenario. For this purpose, I count on the outstanding collaboration of all people who are hearty involved with their time and expertise with our Journal and ask all the endocrinology community around the world to submit their manuscripts to us.


Taro is an important potato crop, which can be used as food, vegetable, feed, and industrial raw material. The yield and quality of taro are primarily determined by the expansion degree of taro bulb and the filling condition of starch, whereas the expansion of taro bulb is a complex biological process. However, little information is reviewed on the research progress of bulb expansion and starch enrichment in taro.PubMed, Web of Science, and the China National Knowledge Infrastructure databases were searched for relevant articles. After removing duplicate articles and articles with little relevance, 73 articles were selected for review.This article introduces the formation and development of taro bulb for workers engaged in taro research. The content includes the process of amyloplast formation at the cytological level and changes in bulb expansion and starch enrichment at physiological levels, which involve endogenous hormones and key enzyme genes for starch synthesis. The effects of environment and cultivation methods on taro bulb expansion were also reviewed.Future research directions and research focus about the development of taro bulb were proposed. Limited research has been conducted on the physiological mechanism and hormone regulatory pathway of taro growth and development, taro bulb expansion, key gene expression, and starch enrichment. Therefore, the abovementioned research will become the key research direction in the future. Taro is an underground bulbous crop planted in the tropical and subtropical regions. It is originated in China, India, Malaysia, and other regions and is widely cultivated in Asia, Africa, and other regions. It has a cultivation history of more than 2,000 years in China. At present, taro can be classified using three methods. Based on the ecological type, taro can be classified into two, namely, aquatic taro planted in paddy field and dry taro planted in orchard soil. Based on the eating part, taro can be classified into three, namely, petiole taro whose main edible part is the petiole, flower taro whose main edible part is the flower, and bulb taro whose main edible part is the bulb. Based on the bulb tillering habit, taro can be classified into three, namely, Kui taro, multi-cormel taro, and multi-head taro . The thrThe taro bulb, which is rich in starch and carbohydrates, is a staple food . CompareTaro contains a large amount of dietary fiber and various essential amino acids, but its fat content is low . It is aBased on the statistics of the Food and Agriculture Organization of United Nations, taro is the 14th largest vegetable crop, with a global planting area of 1.6 million hectares and an annual output of 11.7 million tons. The cultivation area in China ranks first in the world, and it has a large number of wild resources and local varieties, which are primarily distributed in southern regions such as Yunnan, Taiwan, and the Yangtze River Basin. In recent years, taro has become an important input and export trade product. The total export trade volume and total value were higher than the imports . With thPubMed, Web of Science, and the China National Knowledge Infrastructure databases were searched for relevant articles. A total of 2,525 articles appeared in the PubMed database using “taro” as the search term, and the date of publication was from 1975/1/1 to 2022/5/1. After narrowing the search using the keywords “bulb of taro,” “bulb expansion in taro,” “bulb starch enrichment in taro,” “amyloplast enrichment process of taro bulbs,” “development of taro bulbs,” “regulation of hormones on bulb development,” “genes in starch synthesis,” and “regulation of hormones on bulb swelling,” 1,532 studies were obtained. Using “taro” as the search term, 2,525 articles published between 1975 and 2022 appeared in the Web of Science database, of which 914 articles were selected as previously described. After removing duplicate articles and articles with little relevance, 73 articles were selected for review.Colocasia esculenta based on its morphological examination. Based on the growth and developmental characteristic of taro . In the early stage of development, amyloplast was mostly distributed at the edge of the cell and then gathered at the center of the cell. At later developmental stages, the number and size of amyloplasts continued to increase  have an inhibitory effect on the development of taro bulbs, but it promotes the development of taro and increases the number of taro . LimitedIn crops primarily underground storage organs, the synthesis and accumulation of starch are complex physiological and biochemical processes, which result from the synergistic interaction of multiple enzymes. The key enzymes of starch synthesis in root crops, such as potato and lotus root, have been widely studied. The changes in AGPase and SSS activities have important effects on starch synthesis in potato tubers . HoweverIn sweet potato, the key enzyme genes of starch synthesis such as AGPase and SS have been cloned into the gene sequence. The expression and regulation of these genes have been studied, and these key enzyme genes play a key role in the sweet potato starch metabolism pathway . The genGBSS I is a key enzyme that controls starch synthesis, and it catalyzes the synthesis of amylose. The development of taro bulbs is a complex biochemical process, including the accumulation of morphogenesis and assimilation products, involving gene expression, material metabolism, nutrient input, and the effect of external environmental conditions . HoweverStarch is the main storage material of taro bulbs, and amyloplasts are organelles that synthesize and accumulate starch. The development of amyloplasts determines the yield and quality of taro. Limited studies locally and abroad have focused on the development of taro corm and amyloplast, and they remain in the preliminary stage. The observation on the fine structure of amyloplast and its proliferation mode as well as the spatial distribution characteristics of taro corm amyloplast remain unclear. In the future, the occurrence, division, proliferation, and enrichment of amyloplasts in parenchymal cells of different types of taro bulbs; the differences in the physical and chemical properties of taro starch at different developmental stages; and the development and enrichment characteristics of amyloplasts in different spatial parts should be focused on.Starch is the main storage material of taro bulbs. The expansion of taro is closely related to the synthesis of starch, and genes related to starch synthesis are closely related to starch enrichment, which directly determine the starch content of taro. Research on starch synthase gene has remarkably progressed in wheat, rice, potato, and other crops, but limited research has been conducted on taro starch synthase gene. Therefore, the differences in the expression of key enzyme genes  for taro starch synthesis, the role of these genes in regulating starch enrichment, and the exploration of individual gene functions will become the focus of research.The expansion of taro bulbs primarily depends on the increase in the number and volume of parenchymal cells, and this process results from the synergistic action of various hormones, particularly IAA, GA, and CTK. Changes in hormones during bulb development and the relationship between hormones and bulb expansion must be investigated. Exploring the relationship between the expression of hormone synthesis genes and signal transduction-related genes and the enrichment of taro starch is of great research significance.Exogenous hormones and plant growth regulators have important regulatory effects on taro bulb swelling, starch enrichment, and yield increase. Therefore, the effects of exogenous substances, such as 6-BA, 2,4-D, GA3, PP333, and 5-aminolevulinic acid, on the development, yield, and quality of taro bulb, as well as the type and concentration of the best exogenous hormone to promote corm expansion and starch enrichment must be studied. Moreover, plant growth regulators must be developed to improve the quality of taro. All efforts will provide important theoretical basis for taro productionThe development of taro bulbs still requires considerable research. With the deepening of research and the solution to key problems, the production of taro will continue to improve, and the development and utilization of taro will be more efficient.


Neuronal intranuclear inclusion disease (NIID) is a rare neurodegenerative illness with characteristic brain magnetic resonance imaging (MRI) manifestations: diffuse symmetric white-matter hyperintensities in lateral cerebral ventricle areas in fluid-attenuated inversion recovery (FLAIR) and high-intensity signals along the corticomedullary junction of the frontal–parietal–temporal lobes in diffusion weighted imaging (DWI). Here, we report a case of adult-onset NIID who was misdiagnosed with Susac syndrome (SS) due to unusual corpus callosum imaging findings.A 39-year-old man presented with chronic headache, blurred vision, tinnitus, and numbness in the hands as initial symptoms, accompanied by cognitive slowing and decreased memory. Brain MRI revealed round hypointense lesions on T1-weighted imaging (T1WI) and hyperintense lesions on T2WI/FLAIR/DWI in the genu and splenium of the corpus callosum. An initial diagnosis of SS was made based on the presence of the SS-typical symptoms and SS-characteristic radiology changes. Furthermore, the patient’s symptoms improved upon completion of a combined pharmacotherapy plan. However, no significant changes were evident 18 months after the brain MRI scan. Eventually, the patient was then diagnosed with NIID based on a skin biopsy and detection of expanded GGC  repeats in the NOTCH2NLC gene.The present NIID case in which there was simultaneous onset of altered nervous and visual system functioning and atypical imaging findings, the atypical imaging findings may reflect an initial change of NIID leukoencephalopathy. Neuronal intranuclear inclusion disease (NIID) is a slowly progressive neurodegenerative condition that is characterized by eosinophilic hyaline intranuclear inclusions in the central and peripheral nervous system, as well as in the visceral organs . The etiThe onset of the disease varies from infancy to approximately between the ages of 60–70 years  and can Here, we report an adult-onset case of NIID in which the patient’s nervous and visual systems were affected simultaneously at onset and the patient had atypical imaging findings of lesions in the corpus callosum. Susac syndrome (SS) was diagnosed initially due to symptom characteristics at disease onset resembling the SS-typical symptom triad and the observation of SS-characteristic radiology changes. An absence of radiology changes for 18 months after the diagnosis of SS had been made led to further investigation, which yielded a corrected diagnosis of NIID based on the identification of a NIID-associated NOTCH2NLC gene variant and the findings of skin biopsy.The case included in the current study was that of a 39-year-old man with no family history of NIID or any other neurodegenerative disease. He was admitted to the hospital in May 2020 after primarily complaining of headache (sharp pain), paroxysmal blurred vision , tinnitus, and numbness of the hands over the preceding 6 months. Upon admission to the hospital, cognitive slowing and impaired memory function were detected by neurological examination; no abnormalities were found in other physical examinations. The following relevant scales were completed: the Mini-Mental State Examination scale , the Montreal Cognitive Assessment scale , and Barthel Index measure of activities of daily living .The results of blood biochemistry, routine blood panel, anti-endothelial cell antibody, anticardiolipin antibody, anti-cyclic citrullinated peptide antibody, antikeratin antibody, antiperinuclear factor, and routine and biochemical cerebrospinal fluid tests were all normal.An MRI scan of the head revealed multiple round hypointense lesions on T1-weighted imaging (T1WI)  and hypeAnamnesis suggested that the patient’s nervous, visual, and auditory systems were likely to have been affected simultaneously, an onset of disease symptoms similar to that seen with SS. Moreover, the symptoms themselves resembled the typical SS symptom triad  , and SS-One month after being discharged, a brain MRI showed multiple round hypointense lesions on T1WI  and hypeThe patient was readmitted to the hospital in April 2021 after complaining of a paroxysmal visual field defect, headache (sharp pain), and hypoesthesia of the right hand. Cognitive slowing and reduced tendon reflex responses were found by neurological examination; no abnormalities were observed during other neurological examinations. The findings of his brain MRI –T and coGenetic testing was conducted with repeat-primed polymerase chain reaction (RP-PCR) and guanine–cytosine-rich PCR (GC-PCR). We observed a 101 GGC  repeat in the 5′-untranslated (5’UTR) region of the NOTCH2NLC gene [normal range < 40 ] [FigureThe timeline of the patient’s disease course is shown in NIID is a clinically heterogeneous illness with a range of clinical manifestations. For adult-onset NIID, dementia was the most prominent initial symptom, followed by ataxia and unconsciousness . AffectePreviously, brain MRI in patients with NIID has revealed diffuse symmetric white-matter hyperintensities in lateral cerebral ventricle areas in FLAIR images  and highSkin biopsy is feasible and helpful for the diagnosis of NIID. The pathological hallmarks are eosinophilic hyaline intranuclear inclusions in neuronal and non-neuronal central nervous system cells, in autonomic nervous system peripheral cells, as well as in visceral organs and skin , 2014. IFurthermore, in this case, FFA of the eyes showed dilated macular capillary and fluorescein leakage from dilated blood vessels. Dilation of macular capillaries leads to an expansion of intercellular space and increased vessel permeability, thereby enabling fluorescein leakage from dilated capillaries. This phenomenon may lead to retinal abnormalities over time. Retinal abnormalities, including dilated macular capillary, may be a very early retinal change in NIID .There is, in addition, one further point to make. For NIID with corpus callosum lesions, it is mainly differentiated from Reversible splenial lesion syndrome (RESLES) and Marchiafava Bignami disease (MBD). In this case, the patient was initially misdiagnosed as SS due to the presence of the SS-typical symptoms and SS-characteristic radiology change. However, in the subsequent progression of SS, branch retinal artery occlusions and sensorineural hearing loss can also be seen, which is not available in NIID, which will help to distinguish the two.There is not yet a standard treatment for NIID. Symptomatic treatment may improve a patient’s quality of life and delay the progress of some symptoms. Analgesics have been reported to be typically effective in relieving the occurrence of NIID headache/migraine . SteroidThis paper presents a NIID case in which the nervous and visual systems were affected simultaneously in early phase of the disease. The brain MRI showed multiple round hypointense lesions in T1WI analysis and hyperintense lesions in T2WI/FLAIR/DWI analysis in the corpus callosum. And the FFA of the eyes showed dilated macular capillary and fluorescein leakage from dilated blood vessels. Referring to previous literature, we consider the small asymmetric round lesions observed could reflect an initial change of NIID leukoencephalopathy, and the dilated macular capillary may be a very early retinal change in NIID. All in all, this report on a case of NIID may be conducive to enriching clinicians’ understanding of the disease based on its particular clinical manifestations and imaging characteristics.The original contributions presented in the study are included in the article/The studies involving humans were approved by the Ethics Committee of Yuhuangding Hospital. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.LyX drafted and revised the manuscript. HZ collected patient information and revised the manuscript. ZL collected and analyzed patient information. HY, LwX, and JZ interpreted the data and edited the manuscript. All authors contributed to the article and approved the submitted version.This work was partially supported by grants from the Yantai Science and Technology Plan Project (2021YD033 and 2018SFGY092).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


In the current study, high-strength boards for the construction industry were developed from renewable natural resources, fibrous hemp shives, and corn starch. During the research, the influence of the composition of the mixture, the processing of raw materials, and technological parameters on the operational properties of the board were evaluated. The influence of the binding material and the water content on the properties of the molded boards was evaluated. It was established that the rational amount of starch is 15% of the mass of the shives, and the amount of water is 10%. It has been established that with the proper selection of the forming parameters of the board, it is possible to avoid internal disintegration of the structure due to the water vapor pressure, increase the bending strength, and ensure uniform sintering of the board throughout the entire volume. It was found that additional processing of hemp shives can increase bending strength by more than 40%. Furthermore, during the processing of shives by chemical means, soluble substances are washed out, which reduces the density and thermal conductivity of the shives. Selection of a rational level of compression allowed us to increase the bending strength of the boards by 40%. The assessment of all factors made it possible to obtain boards with a bending strength of 40 MPa. The additives used made it possible to reduce the water absorption of the boards up to 16 times and obtain non-flammable boards. The thermal conductivity of the resulting boards varied from 0.07 to 0.095 W/(m·K). The analysis of macrostructure and microstructure allowed us to evaluate the process of the formation of bonds between hemp shives. Most boards in construction and furniture industry are made from poor wood or wood processing waste as filler and bound with phenol formaldehyde-based binders ,2. Durin2 that industrial hemp absorbs from the air during growth [Industrial hemp probably receives the most attention for the production of fillers. This attention to industrial hemp is primarily due to the large amount of dry mass obtained per year from one hectare . Additiog growth ,12,13. Hg growth ,15. Fibrg growth .Boards for various purposes have been created from industrial hemp shives for a long time. The resulting properties of the boards vary greatly. This is determined by a whole series of factors: technological parameters, raw materials preparation, raw materials composition, binder selection, etc. .3, the bending strength was 2.4 MPa and the thermal conductivity coefficient was 0.057 W/(mK). To improve board properties such as water resistance, porosity, and visual look, a group of additives were used: water, oil- and alcohol-based colorants, zinc oxide nanopowder, and mineral pigments.Latvian researchers  produced3. The amount of corn starch ranged from 10 to 50% by the weight of hemp shives.Kremensas et al.  created 3. For the production of the control specimens, only wood particles were used, while in the other specimens, 10 and 25% of the wood particles were replaced with hemp shives. The authors found that replacing part of the wood particles with hemp shives allows lighter and stronger boards.Auriga et al.  develope3. For the bonding of hemp shives, different binding materials were used: urea-formaldehyde, formaldehyde-free acrylic resin, and bio-based soy resin. Hemp boards based on soy resin showed the best results in tensile and bending strengths, 0.43 and 13.9 MPa, respectively.Alao et al.  developeSeveral authors indicate that different thermal and chemical treatments allow one to wash out various soluble substances and volatile organic compounds from raw materials of plant origin ,22,23. TThe aim of this work is to develop boards with higher bending strength for use in structural applications. The novelty of this work is that the starch is modified with sodium metasilicate; the ratio of corn starch and metasilicate is evaluated; the effect of pressing, density, starch content, and the chemical treatment of hemp shives on the bending strength is examined, as is the effect of additives on water absorption and flammability; and analysis of the microstructure of the formed boards is performed.3. Corn starch was produced by Cargill Deutschland GmbH, Krefeld, Germany. Corn starch was mixed with sodium metasilicate. The density of sodium metasilicate was 2.61 g/cm³, the melting point was 72.2 °C, and the amount of particles with a size of 16–30 mm was 99%. The sodium metasilicate supplier was UAB Lerochemas, Klaipėda, Lithuania. The expandable graphite ES 350 F5—manufactured by Graphit Kropfmühl GmbH, Hauzenberg, Germany—was used as a flame retardant. The particle size of the expanding graphite was <71 μm 98.0%, the carbon content was 99.70%, the expansion rate 350–700 cm3/g, and the starting temperature was 180–240 °C. Flame retardant was mixed with starch before being introduced into the forming mixture. The Tubiquard 44N non-ionic fluorocarbon resin dispersion was used as a hydrophobizer for the water- and oil-repellent finish of all kinds of textiles. The most common application method is padding mangle, but by adding suitable auxiliaries it can also be foamed and, in this way, applied with good ecological and economic properties. In our case, the hydrophobizer was introduced into the water before it was sprayed into the mixture. The quantity of application depends on the required permanency and the desired effect. The Tubiguard 44N was produced by CHT Germany GmbH, Tübingen, Germany.USO-31 fiber hemp shives, corn starch, sodium metasilicate, water, flame retardant, and hydrophobizer were used to prepare the specimens. Fiber hemp was grown in Lithuania, Šakiai district. The 0–5 mm shives fraction was used for the tests. The bulk density of the shives was 110 ± 5 kg/mThe formation mixtures were prepared from the raw materials available, the compositions of which are given in The quantities of all raw materials were calculated from the mass of dry hemp shives. In this work, untreated and chemically treated hemp shives were used. In a previous work , it was Untreated and chemically treated hemp shives were used for the preparation of specimens. For the tests, fractions of 0–5 mm fraction were used. The data on the shives processing regime are presented in m is the maximum recorded tensile force, in N; l and b are the length and width of the tested specimen, in m2.The binder composition was prepared from corn starch and sodium metasilicate. Raw materials selected in different proportions were mixed with water until a mixture of liquid consistency was obtained. The prepared mixture was applied to two parallel wooden plates, which were compressed with additional weights and hardened for 1 h at a temperature of 160 °C in a drying oven. After curing, the mixture is subjected to a tensile test according to EN 1607  to evaluThe prepared mixture was poured into a pre-prepared mold see . The molThe main indicator that was taken into account when creating the board was the bending strength. We determined the bending strength according to the methodologies specified in the EN 12089  standardm and the moment of resistance of the entire cross-section of the specimen, according to Formula (2):b is the bending strength, MPa; Fm is the maximum load force achieved, N; l is the distance between the supports’ centers, mm; b is the specimen width, mm; and t is the specimen thickness, mm.The bending strength is determined by applying a load to the center of a specimen placed on two supports. The specimen is placed on the supports so that its longitudinal axis is perpendicular to the longitudinal axes of the supports and its center is under the cylindrical loading head. During the test, the loading head moves at a constant adjusted speed so that the maximum load force is reached within 60 ± 30 s. The bending strength was calculated by determining the ratio of the bending moment at the maximum load force FFive specimens with dimensions of (20 × t + 50) × 50 × t mm were prepared for the bending strength test. Before the bending test, the prepared specimens were conditioned in an environment with a temperature of 23 ± 2 °C and a relative humidity of 50 ± 5%.Thermal conductivities were determined for untreated and chemically treated hemp shives as well as for specimens prepared from the boards. Thermal conductivity was determined according to the requirements of the EN 12664 [Specimens prepared for thermal conductivity for at least 72 h were kept at a temperature of 23 ± 2 °C and 50 ± 5% relative air humidity. Specimens with dimensions of 300 × 300 × (from 12 ÷ 15) mm were used to test the thermal conductivity coefficient see .The short-term water absorption of the specimens prepared from the flat prototypes was determined by immersing the specimens in water for a period of 24 h, according to the instructions of method A of the EN 29767  standardp is the short-term water absorption, kg/m2; m24 is the mass of the specimen after partially immersed in water for 24 h, kg; m0 is the initial mass of the dry specimen, kg; and A0 is the area of the lower plane where the specimen is immersed in water, m2.Short-term water absorption after 24 h of soaking in water was calculated according to Formula (3):The combustion tests of the manufactured boards were carried out according to the methodologies specified in the LST EN ISO 11925–2:2010 standard . This teThe view of the tests is presented in An image of untreated and chemically treated shives is presented in According to data presented in the literature, various soluble substances such as sugars, pectin, waxes, paraffin, etc., are washed out with hot water during scallions processing ,30. In Fp = 0. This indicates a statistically significant difference in the results of the subjects. Consequently, the mean value of the density of the treated shives was (88.0 ± 0.994 kg/m3), and the mean value of the untreated shives was (126.8 ± 1.643 kg/m3). The coefficient of determination of treated and untreated shives R2 = 0.920 was obtained. The bulk density factor of treated and untreated shives explains 92.0% of the variance of the thermal conductivity coefficient in the specimens.After chemical treatment of the shives, changes in the density and thermal conductivity of the shives were evaluated. The dispersion analysis conducted  of exper3), and the average value of the untreated shives was (126.8 ± 1.64 kg/m3). The statistic of the F criterion was equal to 200.73, p = 0. This indicates a statistically significant difference in the results of the subjects. The coefficient of determination R2 = 0.962 was obtained.Further studies attempted to equate the bulk densities of treated and untreated shives to assess differences in thermal conductivity. Accordingly, the average value of the bulk density of the shives was  see .p = 0.000. When the amount of starch changed from 10 to 20%, the statistic of F criterion was 8.15, p = 0.00581, and the difference in the mean values of bending strength was also significant. Repeated analysis showed  see . AccordiThe experimental flammability studies conducted showed that the fire spread time values of hemp shive boards can be described according to Equation (11) see .According to the experimental values obtained, the correlation coefficient is equal to 0.995. This shows that the relationship between fire propagation time and the amount of flame-retardant additive is very strong. The coefficient of determination is equal to 0.991, and it can be concluded that the amount of flame-retardant additive even affects the speed of fire spread by 99.1%. The amount of flame retardant was calculated per 1 kg of shives. In our studies, the amount of flame retardant in the mixture varied from 10 to 60 g per 1 kg of shives. A small amount of flame retardant made it possible to significantly reduce the spread of flame: 10 g of flame retardant slowed down the flame spread by about four times, while using a larger amount of flame retardant from 50 to 60 g meant that fire spread did not occur in the boards.p = 0.382.In order to evaluate whether the thermal conductivity coefficient of boards made from differently treated hemp shives differs, a variance analysis was performed. It was checked whether the difference between the averages of the obtained results is significant see . The disp = 0. Since the p-value is less than 0.05, it can be assumed that the regression model is significant. According to Boards made from treated and untreated hemp shives have no difference in thermal conductivity see . The theIn After adding 5 or 10% of starch, most of the surface of the boards is bound, there are no longer large voids where deformation would easily occur, and the surface of the board is smoother, i.e., less porous. The starch binder does not completely cover the entire free volume between the slats b,c, but Further increasing the amount of starch up to 15% completes the filling of individual voids, and the thickness of the starch binder between the layers increases d.The microstructure analysis of the board provides information about the contact zones of starch and hemp shives and their quality .By further increasing the starch content to 10%, continuous starch films are formed in individual contact zones. From Meanwhile, The analysis of the results shows that the use of 15% starch provides the required bending strength, while the structure analysis shows that the 15% starch content in the mixture ensures the formation of reliable contact zones.3. In our work, it was established that when the density is increased by 1.5 times, the strength increases by about 50%. In this case, when the board density is 350 kg/m3, the bending strength should be about 10 MPa. In this way, it can be stated that other factors, such as water content, starch content, and starch–sodium metasilicate ratio—analyzed in our work—can lead to an increase in the bending strength of the panels by approximately two times. Similar results are obtained when modified starch is used [The works of other authors show that the performance properties of the boards created with starch binding material, especially the bending strength, can differ several times ,32,33,34The chemical treatment of hemp shives allowed not only the reduction of the density and thermal conductivity of hemp shives but also the increase of the adhesive interaction between the binder and hemp shives.Proper selection of the starch–sodium metasilicate ratio allows approximately double the adhesion of the binder. The best starch–sodium metasilicate ratio was found to be 0.6.It was established that the selection of a rational amount of starch is related not only to the bending strength, but also to the formation of the macrostructure. By choosing a starch content of 15%, the highest bending strength is achieved, and further increasing the starch content does not result in bending strength results. When 15% starch is used, the gaps between the sheets are filled with a binding material, so the surface of the boards is smooth.2 to 15 t/m2, the density of the boards increases by about 1.5 times and the bending strength is more than 50%.The pressing selected during the board production process affects not only the density of the boards but also the strength indicators. If the pressing is increased from 5 t/mThe selection of the amount of water allows you to create a board without external and internal defects and additionally increase the strength during bending. A change in the water content of 2.5% increases or decreases the bending strength by approximately 40%. The most suitable amount of water has been determined to be 10%.It has been found that the use of additives can reduce the water absorption several times and obtain non-flammable boards.In the future, additional research should be carried out and the coating of boards with additives should be done from the outside of already-finished boards. In this way, the additives would be less negatively affected by the high pressing temperature, and it would be possible to reduce the yield of the additives. In addition, the mixture obtained could be tested by printing with a 3D printer, which should help to obtain an even more continuous structure of the product and better operational properties.


We give upper and lower bounds on this quantity, by the Linear Programming and the Polynomial methods, as a function of the length, size, and minimum distance. Sharper bounds are obtained in the important special case of binary Hamming codes. Finally, several examples are given to illustrate the results of this paper.We study the probability of an undetected error for general  Moreover, a linear k is the dimension of the subspace. For every two vectors C of M is called a q-ary codewords. The minimum distance d of the code C is the minimum distance between any two different codewords in C. The distance distribution of C is defined asLet C is used for error detection on a discrete memoryless channel with q inputs and q outputs. Each symbol transmitted has a probability q-ary symmetric channel q-ary channel Assume that the code p, the better the code performs in error detection. However, this function is difficult to characterize in general.Let codeword ,2. In thC, comparing its q-ary linear C is suitable for error detection or not, whereC such that C in )des (see ). In facdes see ,16)..q-ary cod is the minimum distance of C and kissing number of the linear code C. In 2021, Solé et al. 17], we hTheorem 4.Let C be a q-ary where L (resp. S) denotes the maximum (resp. minimum) of for Proof. p is small enough, then by Equation  If (2) If (3) If Proof. These three bounds can be deduced easily by Equation  and CoroRemark 7., it is necessary to make p small enough. According to the proof of Theorem 4, if The results in Corollary 4–6 in  are actuSimilar to Proposition 1, by Corollaries 1–3 in , we haveProposition 2.If C is a q-ary linear code, then we have the following statements:(1) If (2) If (3) If When using quadratic polynomials, we have the following bound.Proposition 3.Let then, for a binary where Proof. It is known that, when weight enumerator of the code C is the homogeneous polynomialRecall that the Let Note thatre p∈0,1/, thenThe bounds obtained from the linear programming problem are given in Theorem 4. The bounds obtained from the Polynomial Method are given. According to the main Theorem 5, we get Theorem 6 (applied to the codes with even distances) and Proposition 3.(2)Combining the results of , we give(3)We find sharper bounds for binary Hamming codes (see Theorems 7 and 8).In this paper, we studied the probability of an undetected error To the best of our knowledge, that is the very first time that the LP method has been applied to bound p is small enough and the kissing number To sum up, our bounds are most useful when the exact weight distribution is too hard to compute. Our bounds perform well when q-ary Hamming codes with We mention the following open problems. The readers interested in Hamming codes are suggested to derive bounds for general


Kidney transplantation is the preferred therapeutic option for end-stage renal disease; however, the alloimmune response is still the leading cause of renal allograft failure. To better identify immunologic disparities in order to evaluate HLA compatibility between the donor and the recipient, the concept of eplet load has arisen. Regular kidney function monitoring is essential for the accurate and timely diagnosis of allograft rejection and the appropriate treatment. Donor-derived cell-free DNA (dd-cfDNA) has been proposed as a potential biomarker of acute rejection and graft failure in kidney transplantation. The proportion of plasma dd-cfDNA was determined in forty-two kidney patients at 1 month after transplantation. A total of eleven (26.2%) patients had a dd-cfDNA proportion of ≥1.0%. The only pretransplant variable related to dd-cfDNA > 1.0% was the HLA class II eplet mismatch load, mainly the HLA-DQB1 eplet mismatch load. Furthermore, dd-cfDNA was able to discriminate the patients with antibody-mediated rejection (AbMR) (AUC 87.3%), acute rejection (AUC 78.2%), and troubled graft (AUC 81.4%). Increased dd-cfDNA levels were associated with kidney allograft deterioration, particularly rejection, as well as a greater HLA class II eplet mismatch load. Consequently, combining dd-cfDNA determination and HLA eplet mismatch load calculation should improve the assessment of the risk of short- and long-term allograft damage. Kidney transplantation is the preferred therapeutic option for end-stage renal disease. In this research field, a marked improvement in one-year graft survival rates has been shown , althougThe concept of eplets has emerged as a novel method to fine-tune the HLA risk and better identify immunologic disparities in a more detailed way in order to evaluate HLA compatibility between the donor and the recipient, which may lower the risk of allograft rejection ,8,9,10. Effective immunosuppressive treatments are another important strategy for ensuring long-term transplant survival . NonetheSeveral biomarkers, including serum creatinine levels and estimated glomerular filtration rate (eGFR), are used to monitor graft function and rejection, but their capacity to identify early damage is limited and they may not discriminate acute from chronic graft damage ,18. The As a result, non-invasive and new indicators of early and late graft failure in renal transplantation are required to enhance complication management and increase patient and graft survival ,21. To aWe conducted this prospective study in accordance with the principles outlined in the Declaration of Helsinki and with approval from our institution’s Regional Ethics Committee . We enrolled a total of 42 consecutive recipients of kidney transplants from deceased donors, spanning from January 2021 to April 2022. All the participants provided written consent before undergoing kidney transplantation. We excluded recipients who had received non-kidney solid organ transplants, those from non-controlled cardiac death donations, individuals with preformed donor-specific antibodies, and those with a panel-reactive antibody level exceeding 98%.We gathered relevant information regarding the recipients, donors, and transplant characteristics. Biopsy confirmation was required for all acute rejection episodes. Indication biopsies were performed when creatinine levels increased by 25% or more compared to the previous value, or when there was persistent proteinuria exceeding 1 g per day. We defined a “troubled” graft as one undergoing acute rejection or other issues, such as obstruction or graft infection. Maintenance immunosuppressive therapy consisted of twice-daily doses of tacrolimus, mycophenolate mofetil, and prednisone. Mycophenolate mofetil was started at 500 mg twice daily, whereas the initial tacrolimus dose was 0.1 mg/kg twice daily. The target tacrolimus blood levels at our institution for the first 3 months ranged from 8 to 12 ng/mL. Recipients of organs from expanded criteria donors and those at risk of delayed graft function received basiliximab induction therapy. Thymoglobulin was used as induction therapy for patients at a higher risk of rejection due to hypersensitization or previous graft loss caused by acute rejection. All patients received trimethoprim–sulfamethoxazole prophylaxis for 6 months post-transplant, and valganciclovir was given for 3 months to CMV IgG-negative recipients of a CMV IgG-positive donor and in patients receiving thymoglobulin induction.g for 20 min and 16,000× g for 10 min, plasma was obtained. cfDNA was extracted using the QIAamp Circulating Nucleic Acid Kit  and to determine the relative amount of dd-cfDNA, a targeted NGS assay employing 202 single nucleotide polymorphisms (SNPs) was then utilized   . First, We quantified the concentration of mycophenolic acid (MPA) in human plasma (mg/L) using a homogeneous enzyme immunoassay  at the one-month mark. Whole blood concentrations (µg/L) of tacrolimus were determined using chemiluminescent microparticle immunoassay  on the Architect iSystem. We collected tacrolimus levels up to day 30. We assessed the variability of tacrolimus blood levels using the coefficient of variation (CV), calculated as CV (%) = (σ/μ) × 100, where σ represents the standard deviation, and μ denotes the mean tacrolimus concentration of all available samples . We detehttp://www.epitopes.net/downloads.html accessed on 15 April 2023) was used to assess eplet matching.Antigen HLA and eplet mismatch load were calculated to establish donor and recipient compatibility. The HLAMatchmaker 3.1 software .The median and interquartile range (IQR) were used to express continuous variables, and relative frequencies were used to characterize categorical variables. To compare continuous variables among dichotomous data, the Mann–Whitney U test was used, and the chi-square test was used to investigate the relationship between two qualitative variables. The ability of dd-cfDNA% to distinguish between rejection and troubled graft was examined via receiver operating characteristic (ROC) curves. Statistical significance was defined as a p = 0.022 and p = 0.041, respectively) (The main patient characteristics are shown in ctively) . InteresAs presented in p = 0.007) (p = 0.020) (p = 0.001) (p = 0.004) (p = 0.017) (p = 0.001) (p = 0.035), independent of renal function. Notably, AbMR did not relate to a higher eplet mismatch load.dd-cfDNA was able to discriminate those patients with AbMR  A, with a= 0.020) B, and wi= 0.001) C. Patien= 0.004) A, acute = 0.017) B, and tr= 0.001) C had sigRegular graft function monitoring in kidney transplant recipients is critical for the accurate detection of graft deterioration and starting appropriate therapy to avert graft loss. dd-cfDNA has emerged as a new and non-invasive biomarker for graft injury in kidney transplants, with evidence that it overcomes the limitations of traditional approaches. It has been demonstrated that a dd-cfDNA level of >1.0% is associated with active rejection (AbMR or TCMR), and that those patients with levels of dd-cfDNA of 1.0% or below do not show active rejection . Accordip = 0.020), especially AbMR , from those without rejection. This ability to discriminate those patients with rejection has been proved in a previously reported study. Sigdel et al. [Similarly, we demonstrated that dd-cfDNA levels ≥ 1.0% can differentiate patients with acute rejection . In line with this, Goussouss et al. [Furthermore, we investigated the ability of dd-cfDNA to distinguish various sources of allograft damage or loss of function. Patients were classified into two groups: troubled graft, if the graft was suffering acute rejection or any other problem such as obstruction or graft infection, and non-troubled graft. dd-cfDNA levels of more than 1.0% were able to distinguish between these two groups . Moreover, in recent years, the importance of antigen HLA-DQ matching for transplant outcome has been highlighted [p = 0.041). HLA matching between potential donors and recipients is assessed in kidney allocation by comparing their HLA antigens in order to have a successful transplant outcome, limiting the possibility of sensitization and subsequent rejection [In histocompatibility laboratories, antigen HLA mismatch is a common examination factor in kidney transplant candidates. However, the idea of epitope “load” has recently emerged as a novel technique to better characterize donor–recipient immunologic compatibility in solid organ transplantation. Matching recipients and donors according to the level of epitopes, as compared with traditional antigen HLA typing, may improve risk prediction for the development of donor-specific antibodies implicated in AbMR . Thus, whlighted . Severalhlighted ,44,45, whlighted . In thisejection . UnexpecThe main limitation of this single-center study was the sample size; we could only assess dd-cfDNA% in forty-two kidney transplant recipients one month after transplant. Because of the small sample size, the number of events, especially TCMR, was limited, restricting the capacity to demonstrate the relationship between dd-cfDNA and this type of rejection. Our study, on the other hand, has certain advantages. We conducted a prospective analysis on a cohort of kidney transplant patients who were followed in a single center, and all rejections were biopsy-proven. Furthermore, we conducted an in-depth study of the eplet mismatch load, which has not previously been associated with the percentage of dd-cfDNA.Our findings support the value of measuring dd-cfDNA to detect alloimmune damage, particularly AbMR, in kidney transplantation. Only recipients with a high eplet mismatch load with their donors and an elevated percentage of dd-cfDNA were at risk of acute rejection and AbMR. Furthermore, an optimum assessment of the risk of short- and long-term allograft injury should involve the quantification of both the eplet mismatch load and post-transplant dd-cfDNA percentage.


Guidelines for Medicine Donations. The need for revisions is timely given the large-scale influx of medicine donations since the start of the COVID-19 pandemic. This study analyses current policies of donors and recipients that are commensurate with the recommendations in the Guidelines and examines current practices, challenges, and revision suggestions.To help promote the effective delivery of drug donations, the World Health Organization (WHO) developed the Guidelines were incorporated. We identified 38 policies from 1 donor country, 6 brand-name multinational pharmaceutical companies, 6 NGOs and 25 recipient countries. Most policies incorporated all 12 recommendations. Twenty-five of the 38 policies were developed in 2010 or later. The majority of actual donors and recipients did not have policies that were publicly available. A rapid literature review for publications from 2010 onwards identified challenges in implementing the WHO Guidelines and suggested for revisions. Challenges included: (1) information management; (2) medication presentation; (3) influence from the pharmaceutical industry; (4) donation sustainability; and (5) the belief that donations are inherently good.A search for medicine donation policies of donors and recipients was conducted in May/June 2022 and repeated in January 2023. Potential donor countries were identified from the high-income countries on the United Nation’s (UN) List of G20 Countries. Potential pharmaceutical company donors were selected from those with 2021 revenue of $30 billion or greater. Potential non-government organization donors came from the WHO list of non-governmental organizations (NGOs) and two other sources. Potential recipient countries were those on the UN List of Least Developed Countries. These four lists were supplemented with actual donors and recipients identified from the literature. All policies retrieved were screened to identify which of the 12 recommendations from the WHO Guidelines and both groups should be consulted on any revisions to ensure that their experiences are reflected and their needs are addressed. While the current WHO Guidelines for Medicine Donations are a solid base for medical humanitarian efforts, evidence points to the need for an update to meet current challenges.Our findings suggest that both donors and recipients could further align their policies with the existing The online version contains supplementary material available at 10.1186/s12992-023-00964-3. Guidelines for Drug Donations was published in May 1996  is not updated. Or, if a national list is not available, it should appear on the WHO model lists of essential medicines, unless specifically requested otherwise and provided with a justification by the recipient.The presentation, strength, and formulation of donated medicines should, as far as possible, be similar to those of medicines commonly used in the recipient country.All donated medicines should be obtained from a quality-ensured source and should comply with quality standards in both donor and recipient countries. The WHO Certification Scheme on the Quality of Pharmaceutical Products Moving in International Commerce should be used.No medicines should be donated that have been issued to patients and then returned to a pharmacy or elsewhere, or that have been given to health professionals as free samples.After arrival in the recipient country all donated medicines should have a remaining shelf-life of at least one year. Large quantities of donated medicines become a logistical challenge, even with a long shelf-life. Therefore, based on the national consumption and available quantities in stock or in the supply chain pipeline, all donated quantities should match the needs to be consumed before they are expired.All medicines should be labelled in a language that is easily understood by health professionals in the recipient country. The label on each container should contain at least the International Nonproprietary Name (INN) or generic name, batch number, dosage form, strength, name of manufacturer, country of manufacture, quantity in the container, storage conditions and expiry date.Donated medicines should be presented in pack sizes that are suitable for the recipient and appropriate to the setting in which they will be distributed or dispensed.All medicine donations should be packed in accordance with international shipping requirements and should be accompanied by a detailed packing list that specifies the contents. The weight per carton should preferably not exceed 30 kg. Shipments of medicines should not be mixed with other supplies, unless they are shipped as kits with predetermined contents.Medicine donations should be jointly planned, and collaboration between donors and recipients should begin early. Medicines should not be sent without prior consent of the recipient.In the recipient country the declared value of a medicine donation should be based on the wholesale price of its generic equivalent in the recipient country, or, if such information is not available, on the wholesale world-market price for its generic equivalent.Costs of international and local transport, warehousing, port clearance and (customs) storage, handling and disposal or reverse logistics of expired donated products should be paid for by the donor agency, unless specifically agreed otherwise with the recipient in advance.Four core principles underly these practices. These are:Medicine donations should benefit the recipient to the maximum extent possible. As a result, all donations should be based on an expressed need and unsolicited donations are discouraged.Medicine donations should be made in compliance with the recipient country’s prevailing government policies and administrative arrangements.Effective coordination and collaboration should be fostered between medicines donor and recipient countries, with all donations made according to a plan formulated by both parties.No double standard in product quality should be considered acceptable. If the quality of a product is unacceptable to a donor country, it is unacceptable for that product to be donated to a recipient country.Guidelines, undertaken in 2015 [Guidelines. Cañigueral-Vila et al. [Evidence-based reviews of country compliance with the 2010  in 2015  and 2019 in 2015  respectia et al.  discussea et al.  concludeGuidelines recommendations and proposes recommendations for further revisions based on a survey of the literature focused on guideline implementation challenges.Building on those reviews, this paper analyses current medicine donation policies developed by donor and recipient countries and key organizations. It evaluates congruence between their policies and the We identified and screened three groups of possible donors and one group of possible recipients. We refer to “potential” donors and recipients because in advance of our search we did not have any knowledge about whether these actors had actually participated in donations. The definition of a donor country was when the government of a country arranged a donation. In contrast to the definition of a donor country, a recipient country was defined as the country where the donation was received regardless of whether the actual recipient was the government or an institution/organization within the country.https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groupsSa).Potential donor countries were identified in a two-step process. We initially used the G20 list of countries because they collectively represent 84% of the global economy,  and are https://www.humanrightscareers.com/issues/biggest-ngos-in-the-world/), the WHO list of Non-governmental Organizations  and suggestions from one of the authors (DD) who works in the WHO Department of Health Products Policy and Standards.Potential pharmaceutical company and non-governmental organization (NGO) donors were identified based on revenue and global footprint. Pharmaceutical companies examined were those with 2021 revenues larger than $30 billion. NGOs included for examination were those listed on a combination of Human Rights Careers’ list of “Biggest NGOs in the World” (https://unctad.org/topic/least-developed-countries/list). Recipient countries were limited to LDCs because these countries are those most likely to face significant financial barriers to access, and thus the most likely candidates for medicine donations . In addition, countries in the LDC group were the most likely to be listed as donation recipients in the article by McDonald et al. [Potential recipient countries were identified based on United Nation’s Least Developed Countries (LDCs) status, with no restriction on geographic scope .Finally, the list of examined donors and recipients was cross-referenced against the list of actual donors and recipients named in the article by McDonald et al., as it is the most comprehensive and recent list of drug donations. Donors and recipients identified within that article were added to the list of potential donors and recipients if they had not yet been identified. The income status of these additional recipient countries was determined in reference to their World Bank income classification , 41 NGOs and 66 recipient countries . Table https://www.fda.gov/media/80536/download.) Twenty-five of the 38 policies were developed in 2010 or later, i.e., at the time or after of the latest revision of the WHO Guidelines, while 7 policies were undated. Out of those 25 recently developed policies, 16 had all 12 WHO recommendations.Drug donation policies were identified for 1 donor country, 6 brand-name multinational pharmaceutical companies, 6 NGOs and 25 recipient countries . , 4  and 12 . Thirteen of the 25 recipient countries implemented all 12 WHO recommendations. The recommendations most often excluded from recipient countries’ drug donation policies were recommendations 6 (donated medicines should have a remaining shelf-life of at least one year), 9  and 11 .Of the 5 donor countries, 20 donor pharmaceutical companies, 15 donor NGOs, and 26 recipient countries specifically mentioned in the McDonald et al. article, only 1 donor country, 3 donor pharmaceutical companies, 3 donor NGOs and 13 donor recipient parties had identifiable drug donation policies in place , pharmaceutical companies (6 policies), NGOs (6 policies) and recipient countries (25 policies). Twenty-five policies were implemented in 2010 or later and 16 of those incorporated all 12 recommendations from the most recent Recommendations 11 and 12 were the most likely ones to be missing, primarily in the recipient countries. These two recommendations focus on ensuring that the value of donated medicines match the wholesale price of the equivalent in the recipient country, and that all logistical donation costs are covered by the donors, respectively. The lack of implementation of these recommendations into recipient countries’ policies could allow for donors who also may have not incorporated them into their policies to leave wholesale price matching and donor accountability of logistical costs out of the conversation. This absence creates a cycle whereby recipient countries that do not have highly developed economies are sometimes be forced to pay out of pocket for some of the costs associated with the medicines they are being donated to them, creating a financial burden to them.Guidelines because recommendation 11 states that all donated medicines should match the wholesale price of the generic equivalent in the recipient nation. If this recommendation is not fulfilled, prices with higher mark-ups coming from donor countries can make the overall pharmaceutical market too expensive for citizens in recipient countries and pose another barrier to essential healthcare. Recommendation 12 also states that donors should cover logistical costs in the donation process, as recipient countries should not have to incur additional financial burdens if they are facing a crisis or do not have a large enough healthcare budget.In addition, some authors have raised the risk that large-scale donations may distort pricing in the global commercial market for pharmaceuticals . This diGuidelines can hurt those countries they are intending to help by creating additional financial burdens. This precaution and consideration when incorporating the WHO recommendations into donation policies can mean the difference between pharmaceutical aid that is genuinely beneficial, and aid with underlying financial hinderances for recipients to endure once the medicine arrives [The findings from our study point out the need for stakeholders to focus on the economic implications that their donations can have on other participating actors, especially recipient countries. In-other words, donations that do not comply with the  arrives .We also found that there are many actors across all categories  that do not currently have medicine donation policies or possibly their policies are not accessible to the general public for reference. This was evident in our search especially amongst donor countries, as we were only able to discover medicine donation policies for 1 out of the 12 countries.Guidelines. Actors could also hope to gain more trust from the general public if they make audiences aware of how medicine donations operate within their organizations, which could in turn provide them with more support, funding opportunities and international partnerships in the future.A lack of transparency in medicine donation policies must be addressed. If actors do not currently make medicine donation policies publicly available, other actors and individuals outside of their organization will lack valuable information which may impact potential donation partners who are looking to work with them to donate or receive medicines. If all medicine donation actors shared their current policies, actors could hold each other accountable and provide suggestions to improve their policies to be more in line with the 2010 WHO The difficulties in implementing the guidelines that we identified in the literature strongly suggest the need for a new round of revisions.Guidelines recommendations that were synthesized based on our findings. They are as follows:There are six suggestions for revision to the Include a distinct definition of who is a “recipient” in the donation process to improve clarity between stakeholders. This will allow for all parties involved in the donation process to understand their roles and the roles of others to maximize efficiency and communication.Synthesize a list of successful global case study examples to assist guideline users.Provide a mechanism for recipient countries to decline donations.Use flowcharts to represent the mechanics of medicine donations.Create visuals to illustrate how stakeholders can efficiently operate pharmaceutical interventions to provide aid to recipients.Guidelines to lead their medical humanitarian aid efforts.Donors that do not have a donation policy should reference the 2010 WHO Overall, we also found very minimal academic and public discourse on emergency preparedness in the context of disaster relief efforts and medical donations. One potential area for further action, is the implementation of “virtual” donation exercises for disaster preparedness training . This woAlthough we believe that our search criteria were comprehensive, we may have missed finding policies of some donors and recipients, including because the policies were not publicly available. It is almost certain that there are other donors and recipients who fell outside our inclusion criteria who may have policies that we failed to capture and our results do not apply to these actors. We also did not evaluate how rigorously policies were applied by either donors or recipients. Finally, even in the absence of policies, donors in all three categories are making donations and countries are receiving donations.Guidelines for Medicine Donations provide a foundation for medicine donations, the evidence we found points to the need for further policy development to meet current challenges and more widespread adoption of the Guidelines by all actors. Understanding what has and has not worked in practice is essential for ensuring that the Guidelines remain up to date. Our findings suggest that both donors and recipients could further align their policies with the existing Guidelines and both groups should be consulted on any revisions to ensure that their experiences are reflected and their needs are addressed. Donors and recipients should also produce publicly available annual reports to summarize their donation efforts each year. Full implementation of the Guidelines would maximize the positive impacts of medicine donations for countries in need.While the current WHO Below is the link to the electronic supplementary material.Supplementary Material 1


Correction to: International Journal of Clinical Oncology (2022) 27:563–57310.1007/s10147-021-02091-8In the original publication, in Table 6, the p-values of Number of metastases, mean ± SD under IMDC intermediate risk were published incorrectly. The corrected version of Table The original publication has been updated.