Introduction: The present study was done to analyze the functional outcome, donor site morbidities, and associated parameters when using the anterior half of the peroneus longus for augmentation of an inadequate hamstring graft when performing arthroscopic anterior cruciate ligament (ACL) reconstruction.Methods: Thirty patients with complete ACL tears were operated on. In all these patients, the thickness or length of the hamstring graft taken was found to be inadequate . So, additionally, the anterior half of the peroneus longus tendon (AHPLT) graft was harvested to reach an optimum size of the final graft. Functional outcome was assessed using the International Knee Documentation Committee (IKDC) score at six weeks, three months, and six months. The Foot and Ankle Disability Index (FADI) score at six months was used to assess ankle stability.Results: The mean age in our study was 28.8 years with male predominance (73.33%). The mean operative time was 86.4 minutes. The mean hamstring graft thickness in our study was 6.5 mm, which improved to 9.12 mm after augmentation. The mean graft length after AHPLT augmentation was 9.38 cm. The mean IKDC score at six months was 87.35. At the end of six months, FADI scores were found within normal limits (range: 135-136) in all the patients. No complications were noted in any of the patients.Conclusion: The AHPLT graft was always found to be sufficient enough for augmenting the hamstring graft to reach an acceptable thickness and length. There was no graft site morbidity and the ankle functional levels remained the same as preoperative levels, making it an excellent choice for augmentation of inadequate hamstring grafts. The anterior cruciate ligament (ACL) is the main restraint in the knee to prevent anterior translation of the tibia over the femur  and playThe ultimate aim of reconstruction of the ligament is to re-establish the stability of the injured knee and facilitate an early return to day-to-day activities, including sports, and to prevent the onset of osteoarthritis as well as damage to the meniscus -7. DurinA good amount of literature is presently describing successful ACL reconstruction with the use of donor autografts (hamstring tendon (HT), patellar tendon, and quadriceps tendon) and allografts . Amongst them, bone-patellar tendon-bone (BPTB) autograft and HT are the most commonly used. Despite being highly successful, BPTB is associated with concerns about donor site morbidity such as knee pain (mostly anterior side), extension lack, and fracture of the patella ,9. WhereSeveral studies have revealed that hamstring grafts with a diameter of less than 8 mm are more prone to failure than thicker grafts and have a higher incidence of revision surgery ,13. SpraTherefore, in this study, we have proposed harvesting only the anterior half of the peroneus longus tendon (AHPLT) to reinforce the HT graft where the graft diameter was less, and the remaining portion of the PLT was left for normal function. Zhao et al. (2012) conducted a study describing the biomechanical features of the AHPLT along with its safety, adequacy, and effectiveness. They concluded that it was a good autograft, considering its bearing force, safety, and risks . In addiIn this study, we have used the AHPLT to augment the hamstring graft in arthroscopic reconstruction of ACL in patients where the quadrupled HT graft was found to be inadequate in terms of length or diameter. As different patients have different symptoms, functions, and sports activities, patients differ in a variety of knee problems as some have adequate musculature and some do not have adequate musculature. We have studied the functional outcome of the procedure as well as donor site morbidity and any associated complications.The study was conducted in the department of orthopedics at a tertiary care hospital in South Rajasthan from September 2020 to December 2021 after approval from the Institutional Research Review Committee, Geetanjali Medical College and Hospital ) and taking informed consent from the patients. All the patients with complete ACL tears and those 18 years of age or older were included in this study. A complete ACL tear was confirmed by clinical tests and MRI.The patients were informed that intraoperatively, if the thickness of the hamstring graft was found to be inadequate, then an AHPLT graft would be harvested to supplement the hamstring graft and the patient would be included in the study . PatientFirstly, diagnostic arthroscopy was performed and any meniscal procedure required was done at this stage. Then the hamstring graft was harvested with a 3-cm oblique anteromedial incision on the tibia, the incision being taken approximately 3.5-4.5 cm distal to the knee joint line and 2.5-3.5 cm medial to the tibial tuberosity. Subcutaneous dissection was done, and after exposure of pes anserinus from its insertion, 2 cm medial to the tendinous insertion, gracilis and semitendinosus tendons were palpated and both the tendons were harvested after releasing their fibrous attachment. The ACL graft master was then used to prepare the grafts. In our study, we have taken grafts of a minimum size of 7 mm long and 8 mm in thickness. According to various studies, the graft should be at least greater than 8 mm for better functional outcomes ,12. If tThe distal end of AHPLT is then cut just above the lateral malleolus and it is then harvested using a stripper. The harvested AHPLT was then reinforced into the insufficient hamstring graft Figure .For the preparation of the femoral tunnel, with the arthroscope in the anterolateral portal, the femoral footprint of the ACL is identified in the medial wall of the lateral condyle, debrided, and marked. A guidewire is then drilled through the center of the anatomical footprint. The position of the guidewire was also checked with the arthroscope in the anteromedial portal. If found satisfactory, then drilling with a 4.5 mm cannulated drill bit was done "inside out." The length of the hole was then measured with a depth gauge and the size of the endo-button suspensory device was decided so that at least 2 cm of the graft remains in the femoral tunnel. The tunnel is then reamed with the reamer of the size of the thickness of the graft, at least 6 mm longer than the length of the graft to be retained inside the femoral tunnel, to allow the flipping of the endo-button. The tibial guide is then used to insert a guidewire from the medial part of the proximal tibia at a 25-degree angle from the midline in the coronal plane, at an inclination of 55 degrees in the sagittal plane, and made to exit on the lateral slope of the medial tibial spine. The tibial tunnel is then drilled to the same size as the thickness of the graft. The graft is then inserted through the tibial and femoral tunnels and fixed on the femoral side by an endo-button suspensory device and on the tibial side by a screw, after cycling the knee 20 times.The entry for the tibial tunnel was made through the incision made for harvesting the hamstring graft. The tibial guide was positioned at the tibial footprint of the ACL located in line with the lateral slope of the medial aspect of the tibial spine, at the posterior aspect of the anterior horn of the lateral meniscus, and approximately 1.5 cm anterior to the PCL insertion at an angle of 50-60 degrees. The external part of the tibial guide was positioned flush with the anteromedial tibia, approximately 15 mm medial to the tibial tuberosity and 10 mm proximal to the pes anserinus attachment. After that, a 2.4 mm guide pin for the tibia was inserted through the guide until the tip of the pin was not visible protruding through the tibial footprint. Subsequently, the graft was passed through the tunnels thus made and was fixed on its femoral insertion site using an endo-button suspensory device and to that of the tibia by bio-interference and metal screws of suitable length and thickness. Wound closure was done in layers, a compression bandage was applied and a long knee brace was given.Knee mobilization exercises were permitted from the evening after surgery and ambulation was allowed with a long knee brace. On postoperative day one, patients were put on the postoperative ACL rehabilitation protocol, which included knee mobilization exercises, quadriceps strengthening exercises, and ankle pumps. The goal was to achieve a 90-degree range of motion (ROM) in the first two weeks and a 120-degree ROM by the fourth week. The patients were followed up after two weeks for an inspection of the wound and the removal of sutures. The long knee brace was continued up to six weeks post-surgery and was advised to be worn only during ambulation.The functional assessment of the patient was done using the International Knee Documentation Committee (IKDC) score and clinical examination for anteroposterior stability at six weeks, three months, and six months follow-up . To clinDuring the period of January 2020 to May 2021, 30 patients who were operated on for arthroscopic ACL reconstruction using hamstring graft required an AHPLT graft augmentation, and all these patients were studied. The age range of the patients was 18-46 years, with a mean age of 28.8 years. Half (50%) of these patients were in the age group of 21-30 years . It may be because male patients are more active in sports and have higher incidents of road traffic accidents. In our study, 22 patients had right knee injuries, as most of the patients were right-sided dominant (73.2%) Table .The major source of injury was seen to be sports or physical activities (40% of the patients), followed by road traffic accidents (36.63%). Few patients (23%) sustained ACL injuries as a result of minor trauma during routine daily activities Table .All patients presented with the complaint of "giving way" of the knee. Other symptoms included pain (63%), swelling (53.3%), and locking of the knee joint (50%) Table .The medial meniscal tear was the commonest associated injury (46.6%) detected by MRI, followed by lateral meniscus tear 10%), and grade 1 posterior cruciate ligament injury not requiring surgery (3.3%). The mean operative time was 86.4 minutes (range: 75-101 minutes). All demographic data are shown in Table 0%, and gThe mean graft diameter (thickness) in our study before augmentation was 6.5 mm and after augmentation with an AHPLT graft was 9.12 mm (range: 8.5-10 mm). The mean graft length after AHPLT augmentation in our study was 9.38 cm (range: 8-11 cm)  .If left untreated, ACL tears lead to knee instability and potentially debilitating long-term sequelae. The improved results and excellent prognosis, leading to functional outcomes comparable to normal or near normal knees and ensuring a high probability of return to preinjury levels of sports and physical activities, make arthroscopic reconstruction the gold standard for ACL injuries .Graft choice in arthroscopic reconstruction has been a matter of debate. Among the various available grafts, such as BPTB graft, hamstring autograft, quadriceps tendon, various synthetic grafts, and allografts, hamstring autografts had the minimum donor site morbidity. Multiple studies indicate higher strength, stiffness, and cross-sectional area when using multiple-strand hamstring autograft for ACL reconstruction -21.In Pinczewski et al.'s 10-year comparative study of ACL reconstruction with HT and patellar tendon autograft, they reported that HT autograft is superior to BPTB autograft in postoperative knee stability, Lysholm score, and radiographic osteoarthritic change . Helito In a study done by Spragg et al., it was observed that adequate graft diameter is between 9 mm and 10 mm, which significantly reduces revision surgery. In their cohort, the number of revision surgeries decreases with every 0.5 mm increase in graft diameter, from 7 mm to 10 mm, and the requirement for revision surgery decreases by 0.86 times when treated with hamstring autograft with adequate graft size . In our The mean preoperative IKDC score in our study was 45.94, which improved to 87.35 at the six-month follow-up. This improvement in IKDC scores was statistically significant (p < 0.05). The final scores ranged from fair to excellent at six months . We compared the IKDC score with studies of Kumar et al. (2016) , Khan etOur study showed that meniscal injury was seen in 56.6% of patients. Amongst the patients with meniscal injuries, the medial meniscus (n = 14) was injured more frequently than the lateral meniscus (n = 3). Many other studies have also reported the same findings . Among tWe also faced various limitations in our study as we did not include patients with post-traumatic ankle, congenital talipes equinovarus, poliomyelitis, and congenital vertical talus.During their time of stay or throughout the follow-up period, no complications were noted in any of the patients. No patellofemoral pain was noted in any patients, which is a regular observation made in studies of ACL reconstruction using the patellar tendon graft ,9. ThereIn conclusion, we would like to affirm that the AHPLT graft is an excellent choice for the augmentation of insufficient hamstring grafts when performing arthroscopic ACL reconstruction. There is no graft site morbidity and the ankle functional levels remain the same as preoperative levels. Also, it was seen that the AHPLT graft augmentation was always found to be sufficient enough to enhance the hamstring graft to reach an acceptable size and length of the final graft. Thus, we recommend that the use of AHPLT graft for augmentation of hamstring graft in ACL reconstruction is an excellent choice, safe, and gives desirable functional outcomes.


Mechanical surface treatments can deteriorate the mechanical properties of zirconia. This study evaluated and compared the biaxial flexural strength, fracture toughness, and fatigue resistance of high translucency (HT) to low translucency (LT) zirconia after various mechanical surface treatments.6 cyclic fatigue loadings, followed by measuring the residual biaxial flexural strength. Fractured surfaces were examined for critical size defects (c) using SEM to calculate the fracture toughness (KIC). The effect of surface treatments, zirconia type, and cyclic fatigue on the biaxial flexural strength was statistically analyzed using three-way analysis of variance (ANOVA) and Tukey HSD post hoc tests (α = 0.05). Weibull analysis was done to evaluate the reliability of the flexural strength for different materials.Four hundred eighty zirconia discs were prepared by milling and sintering two HT (Katana and BruxZir) and LT (Cercon and Lava) zirconia blocks at targeted dimensions of 12 mm diameter × 1.2 mm thickness. Sintered zirconia discs received one of the following surface treatments: low-pressure airborne particle abrasion (APA) using 50 µm alumina particles, grinding using 400 grit silicon carbide paper, while as-sintered specimens served as control. Internal structure and surface roughness were evaluated by scanning electron microscope (SEM) and a non-contact laser profilometer, respectively. Half of the discs were tested for initial biaxial flexural strength, while the rest was subjected to 10p < 0.001) than that of HT zirconia in all groups. While low APA significantly increased the biaxial flexural strength of LT zirconia, no significant change was observed for HT zirconia except for Katana. Surface grinding and cyclic fatigue significantly reduced the flexural strength of all groups. High translucency zirconia reported higher fracture toughness, yet with lower Weibull moduli, compared to LT zirconia.The initial biaxial flexural strength of LT zirconia was significantly higher (LT zirconia has higher biaxial flexural strength, yet with lower fracture toughness and fatigue resistance, compared to HT zirconia. Low-pressure APA has significantly increased the biaxial flexural strength in all zirconia groups except BruxZir. Grinding was deteriorating to biaxial flexural strength and fracture toughness in all zirconia types. Cyclic fatigue has significantly decreased the biaxial flexural strength and reliability of HT and LT zirconia. Zirconioperties . Zirconiies [1/2 . Howeveries [1/2 .Y-TZP has a submicroscopic grain size in the range of 0.2–0.5 µm and exhibits high opacity because of the inherent birefringence of non-cubic zirconia phases, resulting in light scattering at grain boundaries, pores, and additive inclusions , 9. The The introduction of monolithic or, as known, a high translucency (HT) zirconia restoration with improved optical properties has dispensed the need for the veneer layer . EliminaDifferent surface treatments such as APA and grinding are essential routine steps for better resin bonding to zirconia. However, these surface treatments can deteriorate the mechanical properties of Y-TZP and Y-PSZ and possibly induce surface flaws and microcracks that can propagate under occlusal loads leading to a catastrophic failure , 21. OccTwo LT 3 mol% Y-TZP zirconia  and two HT 4 mol% Y-PSZ zirconia milling blocks  Table  were mila, Rp, and Rv) values were measured using a non-contact laser surface profilometer  where Ra is the mean surface roughness, Rp is the peak surface roughness, and Rv is the valley surface roughness. These parameters were expressed in µm. Grain size and grain boundary regions were evaluated using scanning electron microscopic examination . The size of one hundred grains from each zirconia type was calculated on the obtained SEM images using computer software .Surface roughness parameters  were loaded in a piston on three balls set-up for biaxial flexural strength testing (following ISO: 6872:2015) with the treated surface in tension to evaluate the initial biaxial flexural strength. Discs were loaded at a crosshead speed of 1 mm/min till failure using a universal testing machine  , and examined under a scanning electron microscope . The origin and direction of the fracture were identified and located followed by measuring the size of the critical defect (cr) Fig.  that cauIC) of fractured zirconia bars could be then calculated according to c and Fs values obtained using the following equation[IC) is the fracture toughness in MPa.m1/2, Y is the geometry constant = 1.24 (assuming that there is a lack of pre-stresses at crack origin), and cr is the critical defect size in µm.The fracture toughness  using the maximum likelihood estimation method with a 95% confidence interval (CI) [Weibull modulus (m) was calculated to determine the reliability of the materials according to Quinn and Quinn method . This eqversus σ . Two-parval (CI) .Computer software ) was used to run all the statistical analyses of the obtained data. The normal distribution and homogeneity of variance were checked and verified for surface roughness parameters, fracture toughness, and biaxial flexural strengths data using Kolmogorov–Smirnov and Levene’s tests, respectively. The data were found to be normally distributed. Hence, one-way analysis of variance (ANOVA) was used to compare the mean surface roughness parameters and fracture toughness of the studied groups. However, the effect of different zirconia types, surface treatments applied, and fatigue was analyzed by three-way ANOVA and Tukey HSD post hoc test for multiple comparisons at a level of significance (α = 0.05).2 were frequently interrupted by smaller round grains (0.9–1.6 µm2)  in the surface roughness parameters  between the as-sintered and APA groups regardless of the zirconia type used. However, surface grinding statistically (p < 0.001) increased the surface roughness parameters in all zirconia groups. There was no statistically significant difference (p > 0.05) in the fracture toughness between the Cercon and Lava (LT) or between BruxZir and Katana (HT) zirconia types in the as-sintered groups or the APA groups. Further, no significant difference was detected in ground groups regardless of the zirconia type. Low-pressure APA significantly increased the fracture toughness compared to the as-sintered groups in all zirconia types except for BruxZir; no significant difference was found (p > 0.05). Surface grinding significantly decreased (p < 0.001) the fracture toughness in all zirconia types with no statistical difference between them.Descriptive statistics and one-way ANOVA results of surface roughness parameters and fracture toughness are summarised in Table P2 = 0.987) followed by surface treatments applied (ηP2 = 0.980), and cyclic fatigue (ηP2 = 0.940), while the interaction effect between surface treatments and cyclic fatigue had the lowest impact (ηP2 = 0.046).The 3-way ANOVA results showed that all the independent variables  or their interactions significantly affected the biaxial flexural strength among the studied groups. The greatest influence was for the type of zirconia used  the biaxial flexural strength compared to the as-sintered groups in all zirconia types except for BruxZir zirconia, while surface grinding significantly decreased (p < 0.001) the initial biaxial flexural strength in all studied zirconia types. Cyclic fatigue significantly decreased (p < 0.001) the initial biaxial flexural strength in all zirconia types regardless of the surface treatment employed.Low-pressure APA significantly increased (p > 0.05). However, HT zirconia types (Katana and BruxZir) showed significantly lower initial biaxial flexural strength  with no significant difference between them (p > 0.05). In the APA group, no significant difference was found in the initial biaxial flexural strength between (Cercon and Lava) zirconia , and similarly between (Katana and BruxZir) zirconia . In the surface grinding group, no significant difference was found in the initial biaxial flexural strength between Katana and BruxZir . In comparison, Lava zirconia showed a significantly higher (p < 0.05) mean initial biaxial flexural strength (973.4 ± 23.9 MPa) compared to Cercon (909.7 ± 22.9 MPa). A similar trend of comparing the effect of different surface treatments on the residual biaxial flexural strength of different zirconia types was observed, except for comparing the residual biaxial flexural strength between Katana and BruxZir zirconia ; a significant difference was found (p < 0.001).In the as-sintered group, LT zirconia types (Cercon and Lava) showed closely similar initial  biaxial flexural strength results with no significant difference between them  and decreased both initial and residual flexural strengths. Özcan et al. [Low APA and surface grinding increased the surface roughness parameters with a statistical significance detected in the latter. These findings are in agreement with previous work , 39, 40.n et al.  concluden et al. –44. It hn et al. .Low translucency zirconia had a significantly higher initial biaxial flexural strength compared to HT zirconia. Several studies have related the increase in grain size to the decrease in flexural strength , 48. AccHigh translucency zirconia revealed a higher fatigue resistance, compared to LT zirconia, as it was associated with a lower percentage of reduction in residual strength due to its internal structure, larger grain size, and refined grain boundaries. Some studies found that the percentage of transformation toughening that hinders crack propagation in LT tetragonal zirconia was much higher than HT cubic zirconia –48, so iThe current study showed that the fracture toughness of HT zirconia was higher than that of LT zirconia which can be attributed to the larger grain size of the first  as thereWeibull distribution is commonly used in life prediction analysis of brittle materials such as zirconia . For lonThe presence of deep surface defects introduced by grinding had a direct effect on the reduction of residual strength associated with lower (m) values as reported by previous works , 62. FurThe limitations of the current study can be the use of cylindrical specimens design that do not simulate the anatomical crowns in clinical situations. However, the cylindrical design was easier to standardise for all tested specimens, so that the results can be fairly compared between the tested groups and a conclusion can be precisely drawn. Other limitations can be the use of two LT and HT zirconia types in the study. Supra-high translucent zirconia and ultra-high translucent zirconia are other common brands of PSZ zirconia that should be tested to increase the external validity of the results. Further, crystallographic analysis of treated zirconia types was not done. Assessment of crystalline changes to zirconia after various surface treatments will give a more in-depth understating of how much they can trigger t-m transformation.Low translucency zirconia has higher biaxial flexural strength, yet with lower fracture toughness and fatigue resistance, compared to HT zirconia. Low-pressure APA has significantly increased the biaxial flexural strength in all zirconia groups except BruxZir. Grinding was deteriorating to biaxial flexural strength and fracture toughness in all zirconia types. Cyclic fatigue has significantly decreased the biaxial flexural strength and reliability of HT and LT zirconia.


The role of the indirect T-cell recognition pathway of allorecognition in acute T cell-mediated rejection (aTCMR) is not well defined. The amount of theoretical T-cell epitopes available for indirect allorecognition can be quantified for donor-recipient combinations by the Predicted Indirectly ReCognizable HLA Epitopes algorithm (PIRCHE-II). The PIRCHE-II score was calculated for 688 donor kidney-recipient combinations and associated with the incidence of first-time diagnosed cases of TCMR. A diagnosis of TCMR was made in 182 cases; 121 cases of tubulo-interstitial rejection cases  and 61 cases of vascular TCMR (TCMR II-III). The PIRCHE-II score for donor HLA-DR/DQ (PIRCHE-II DR/DQ) was highly associated with vascular rejection. At one year after transplantation, the cumulative percentage of recipients with a vascular rejection was 12.7%, 8.6% and 2.1% within respectively the high, medium and low tertile of the PIRCHE-II DR/DQ score (p<0.001). In a multivariate regression analysis this association remained significant (p<0.001 for PIRCHE-II DR/DQ tertiles). The impact of a high PIRCHE-II DR/DQ score was mitigated by older recipient age and a living donor kidney. In conclusion, indirect antigen presentation of donor HLA-peptides may significantly contribute to the risk for acute vascular rejection. In parallel, alloreactive CD4+ T cells may also play an important role in acute rejection as they either can directly invade the transplanted organ and cause rejection  after kidney transplantation has decreased over the last decades by more potent immune suppressive drugs, aTCMR still contribute significantly to the incidence of graft loss , 2. The ejection , or supp T cells –7. At pr+ T cells, an algorithm has been developed to identify the Predicted Indirectly ReCognizable HLA Epitopes that can be presented by recipient HLA class II (PIRCHE-II)  . This alantation –13. In aantation , 15 and antation , 17 has + T cell alloreactivity, is related to the incidence of aTCMR in a large cohort of kidney transplant recipients with a complete clinical database and long-term follow-up.In this study, we investigated whether the PIRCHE-II score, as a measure for the potential indirect CD4per protocol biopsies were done. The classification of acute T cell-medicated rejection was made using the Banff 2019 criteria. Per patient, only the data of the first kidney biopsy with a diagnosis of TCMR were used for analysis. Within the first year after transplantation, 99% of all recipients suspected of a possible rejection (decrease in eGFR or unexplained proteinuria) underwent a kidney biopsy.In this retrospective study, we evaluated all kidney transplant recipients from the Erasmus MC between 1995 and 2005. This is a sub-cohort of the PROCARE study which included all kidney transplantations performed in the 7 transplantation centers in the Netherlands within that period . All traPatients were seen in our out-patient clinic at a regular basis at least weekly in the first month after transplantation and at least at a yearly basis beyond the first year after transplantation until death, graft loss or loss to follow-up . The last date of follow-up was December 2021. Graft failure was defined as loss of kidney function necessitating dialysis or retransplantation. Informed consent was obtained from all participants. The clinical and research activities reported are consistent with the Principles of the Declaration of Istanbul as outlined in the ‘Declaration of Istanbul on Organ Trafficking and Transplant Tourism’ and in accordance with the declaration of Helsinki. The use of clinical data and assessment of donor-specific antibodies in stored serum samples was approved by the Research Ethics Committee for Biobanks at the Erasmus MC and the Medical Ethics Committee of the University Medical Center Utrecht.viawww.pirche.com). HLA-A, -B, -C, -DRB1, -DRB3/4/5, and -DQA1/DQB1 were taken into consideration as presented loci, and HLA-DRB1 was considered as the presenting locus. As only HLA typing data at serological level were available in our cohort, the PIRCHE-II peptides and their weights were calculated based on serological typing data, as described previously in detail  and 61 cases of vascular TCMR (TCMR II-III) Figure 1To assess a possible dose-response effect, the PIRCHE-II scores for HLA class I and II were divided into tertiles. Rejection-free survival curves Figure 2A uni- and multivariate logistic regression analysis was performed to calculate the hazard ratios of relevant clinical parameters for the TCMR incidence after transplantation 3. The kA sensitivity analysis was done by assessing the hazard ratio per tertile of PIRCHE-II DR/DQ score in a multivariate logistic regression analysis with strata for relevant risk factors for rejection. Recipients with a cycloporine  or tacrolimus-based immune suppressive regime ; for recipients of a living  or deceased donor kidney ; and for different recipient age groups when divided in young , middle age  and older age . As shown in Finally, the effect of the PIRCHE-II score for the risk of rejection was evaluated in the fully matched recipient-donor kidney combination by serological HLA typing (n=95 transplantations). Eight cases of borderline rejection, 6 cases of TCMR Banff grade I and 2 cases of TCMR Banff grade IIA rejections were documented. These recipients had a significantly higher PIRCHE-II DR/DQ scores compared to the non-rejecting recipients .+ T-cell alloreactivity, is associated with aTCMR after kidney transplantation. A strong association between the PIRCHE-II score for predicted donor HLA II-derived epitopes and the incidence of TCMR was observed, in particular vascular rejection. Sensitivity analysis showed that this association was consistently found in different strata of groups of recipients based upon known risk factors for TCMR like a deceased donor kidney, a younger recipient age and cyclosporine instead of tacrolimus as calcineurin inhibitor , I Bajema, J von der Thussen and M. Clahsen-van Groningen.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.


For the last 11 years, I had a profound pleasure to serve as Editor‐in Chief, and my wife, Grazyna Zareba, PhD, assisted this activity as Managing Editor of the Annals. We have worked for the Annals with a purpose to serve and support the scientific and educational mission of the International Society for Holter and Noninvasive Electrocardiology (ISHNE). I would like to start by thanking my wife for her tireless work on the journal that made my life so much easier and we very much enjoyed working together, capitalizing on our prior collaborative experience with Cardiology Journal, which we help launch in 2006 and managed for several years.Over the last decade, electrocardiology significantly evolved with increasing interest in new technologies acquiring ECG signals using patches, watches, stethoscopes, and other unconventional ECG devices. More than 120 years after the Einthoven's initial ECG recordings, the field of electrocardiology is thriving as the most frequently used test in cardiology if not entire medicine. Nowadays, progress in ECG acquisition devices is paralleled by advances in ECG signal processing becoming more sophisticated, further supported by machine learning and other computerized solutions. ECG does not know the borders or limits, and this is why our journal has been receiving manuscripts from all‐over‐the‐world on a multitude of interesting topics.We were privileged to work with the John Wiley & Sons, Inc. (known as Wiley), the global publisher (founded in 1807) producing our journal with publisher's offices in Beijing and with production offices in New Delhi, with which we successfully collaborated for over decade. Daily tasks related to the Annals completed by my wife in the evening in Rochester, NY, were picked up by our collaborators in New Delhi or Beijing in their morning hours to reach the common goal: to make sure that every issue of the journal is up to the highest standards. We are very grateful to many colleagues from Wiley for their devoted work on the Annals.Our journal is gaining popularity especially since the Annals became in 2020 an open access journal. The annual 2021 Publisher Report (released by Wiley in June 2022) demonstrates a very significant increase in the full‐text article downloads reaching over 600,000 in 2021  program. We are all pleased with Dr. Haigney, agreeing to serve as the next Editor‐in‐Chief of the Annals, the journal entering its 28th year of publication, which will be thriving for many years to come under Mark's leadership.


As Canada’s population ages, there is a need to explore community-based solutions to support older adults. Naturally occurring retirement communities (NORCs), defined in 1986 as buildings or areas not specifically designed for, but which attract, older adults and associated NORC supportive service programs (NORC-SSPs) have been described as potential resources to support aging in place. Though the body of literature on NORCs has been growing since the 1980s, no synthesis of this work has been conducted to date.The goal of this scoping review is to highlight the current state of NORC literature to inform future research and offer a summarized description of NORCs and how they have supported, and can support, older adults to age in place.Using a published framework, a scoping review was conducted by searching 13 databases from earliest date of coverage to January 2022. We included English peer- and non–peer-reviewed scholarly journal publications that described, critiqued, reflected on, or researched NORCs. Aging-in-place literature with little to no mention of NORCs was excluded, as were studies that recruited participants from NORCs but did not connect findings to the setting. A qualitative content analysis of the literature was conducted, guided by a conceptual framework, to examine the promise of NORC programs to promote aging in place.From 787 publications, we included 64 (8.1%) articles. All publications were North American, and nearly half used a descriptive research approach . A little more than half provided a specific definition of a NORC ; of these, 13 (39%) used the 1986 definition; yet, there were discrepancies in the defined proportions of older adults that constitute a NORC . Of the 64 articles, 6 (9%) described processes for identifying NORCs and 39 (61%) specifically described NORC-SSPs and included both external partnerships with organizations for service delivery  and internal resources such as staff, volunteers, or neighbors. Identified key components of a NORC-SSP included activities fostering social relationships  and access to resources and services . Sustainability and funding of NORC-SSPs were described , particularly as challenges to success. Initial outcomes, including self-efficacy  and increased access to social and health supports  were cited; however, long-term outcomes were lacking.This review synthesizes the NORC literature to date and demonstrates that NORC-SSPs have potential as an alternative model of supporting aging in place. Longitudinal research exploring the impacts of both NORCs and NORC-SSPs on older adult health and well-being is recommended. Future research should also explore ways to improve the sustainability of NORC-SSPs. Supporting older adults to age in their communities has been a focus of Canadian aging strategies and policies ,2; howevNORCs have been described by Kloseck et al  as “untaA scoping review was considered the appropriate approach, given the fact that no previous review of the literature had been conducted. Furthermore, our aim is to capture the full breadth of the literature, bringing all scholarly work on NORCs together, as opposed to analyzing the methodological quality of the existing evidence .A scoping review as outlined by Arksey and O’Malley  and updaAs per the recommendations of Levac et al , we keptWe articulated three subquestions to help guide the data extraction:What methods are used in the literature to identify NORCs?What mechanisms or resources are in place in NORCs and how are these provided (delivered)?What outcomes are used to determine the benefits of NORCs?naturally occurring retirement communit*. Expanders to include equivalent subjects and related words were used in some databases. Databases were searched from their earliest data of coverage through January 2022. The following databases were searched: CINAHL, Ovid MEDLINE, HealthSTAR, Embase, APA PsycINFO, Allied and Complementary Medicine Database, JBI Evidence-Based Practice Resources, REHABDATA, Sociofile, Education Source, Education Resources Information Center, Urban Planning, and the Cochrane Library. In addition, the 3 aforementioned review papers [A professional health sciences librarian (Paola Durando) performed the scoping review search in July 2020. A subsequent search was conducted by the authors in January 2022. To conduct a comprehensive search within NORC literature, the only search term used was w papers -7 were enaturally occurring retirement communit*, 787 articles were identified from across the selected databases. These articles were imported and screened for study selection using Covidence screening software . Many of these articles  were duplicates from 92% (12/13) of the databases and removed before screening. A search of REHABDATA yielded zero results. Only duplicates were found in Google and Google Scholar searches. An initial title and abstract screening was conducted, and the inclusion and exclusion criteria were applied to guide final study selection. All titles and abstracts were screened by 2 members of the research team (SD and CF). The inclusion and exclusion criteria are specified in Using the key search term Articles identified in the abstract and title screening as relevant for a full-text review  were reviewed by 2 members of the research team (SD and CF) by applying the inclusion and exclusion criteria. Any discrepancies were reviewed by a third member of the research team (SP) and discussions were held until consensus was reached. Article selection followed the PRISMA  statement, and the study process is described in Inclusion criteriaEnglish languageScholarly sources, including peer- and non–peer-reviewed journalsSubject matterDescriptionsCritiquesReflections on naturally occurring retirement communitiesResearch in naturally occurring retirement communitiesExclusion criteriaNon-EnglishArticle typesBook chaptersDissertationsConference abstractsReportsMagazine or newspaper editorialsSubject matterAging-in-place literature with little or no mention of naturally occurring retirement communitiesResearch that sampled from naturally occurring retirement communities but did not connect results to settingDuring the study selection phase, the authors developed a data charting table. Variables included author, date, location, study design, and NORC definition used. Data extraction was informed by the conceptual framework developed by Greenfield et al , which eAs per the recommendations of Levac et al , 2 authoAs this is a scoping review, ethics approval was not required.Of the 64 articles included in this scoping review, 60 (94%) were written in a US context, with the remaining 4 (6%) written from Canadian perspectives ,14,15. TOf the 64 articles, 33 (52%) provided a specific definition of NORCs. Authors of 20% (13/64) of the articles cited the 1986 definition proposed by Hunt and Gunter-Hunt -33,36-40A subset of articles focused specifically on NORC-SSPs: authors cited definitions from the study by Vladeck  that focAll articles presented NORCs or NORC programs within North America. When locations were specified, NORCs and NORC-SSPs were described in Wisconsin , New York State , Florida , Georgia , Missouri , Maryland , California , New Jersey , and Oregon  in the United States, and Ontario in Canada .naturally occurring, the literature represented a range of NORCs: some authors described vertical NORCs or those in apartment buildings with or without programs , whereas others described horizontal or neighborhood NORCs with or without programs . In addition, authors compared vertical and horizontal NORCs and NORC programs  [Aurand et al  explored/64, 8%) ,46,48,49Among the 64 included publications, the authors of 6 (9%) articles about NORCs described identification processes. The purpose of 33% (2/6) of these articles was to present the process of identifying NORCs ,23; in bAmong the 39 NORC-SSP articles, in 9 (23%), authors described some methods for identifying the NORCs they described: an article presented a 1991 analysis of housing occupancy in New York State to identify potential NORCs . The remThis section of the results builds on the conceptual framework developed by Greenfield et al  to examiIn 72% (46/64) of the articles, authors described resources within NORCs, which are categorized as internal and external resources. Most of the findings presented in this section refer to articles written about NORC-SSPs, rather than geographic NORCs, because NORC-SSPs include programs of some kind.Greenfield et al  define eAn important external partner described in the literature was the landlord or property manager ,52,55,56Other external partners described in the literature included transportation agencies ,24, churGreenfield et al  describeAuthors referred to the role of volunteers in running NORC programs in 22% 14/64) of the articles /64 of th,59,60,62Other internal resources mentioned in the literature included the role of neighbors and other NORC residents in supporting each other ,55,56,62NORC-SSPs typically consist of activities and services to support older adults to age well in their communities. Greenfield et al  categoriNORC-program members were described as actively engaged in 25% (16/64) of the articles. In some articles, empowerment and engagement was described as members taking on volunteer roles within the program ,36,39. EAuthors described activities to build social relationships in 39% 25/64) of the articles. Examples included coffee hours , 62, 64, of the aOf the 64 articles, 26 (41%) presented NORC-SSP offerings, including services that enhanced access to resources. In 16% (10/64) of the articles, authors described the offering of educational classes and guest speakers to the NORC-program memberships, whereas 16% (10/64) presented case management -50,63,65Authors discussed funding and sustainability in 42% (27/64) of the included articles. Among these 27 articles, in 3 (11%), authors broadly discussed the importance of funding NORC programs ,20,38, wAlthough many funding sources were acknowledged, authors described challenges in maintaining the sustainability of NORC programs in some contexts. In the exploration by Greenfield and Frantz  of sustashow promise for the NORC-program concept. Greenfield et al [The articles included in this review presented a range of quantitative outcomes as well as anecdotal descriptions of the influence of NORCS on aging in place. Although the scoping review did not grade the level of the evidence presented in the studies, it is clear that robust outcome studies have not been completed; as a result, this section reports on outcomes that ld et al  organizeInitial outcomes of participating in NORC programs can be grouped into three subcategories: (1) self-reported self-efficacy, collective efficacy, and greater sense of community; (2) self-reported increased social support and reduced isolation; and (3) self-reported access to support and reduced unmet needs.NORC-program participants reported increased self-efficacy  ,52,53,67NORC-SSP members reported increased social support and reduced isolation  through their participation in NORC programs. Increased social supports came from interactions with NORC-program staff, participation in service programs, and their increased interactions with neighbors and friends as a result of membership in the program.NORC-program participants reported access to support and reduced unmet needs , primarily through the program’s function of providing increased access to services and information, including providing referrals, screenings, and educational workshops.Greenfield et al  posit thAlthough the literature connects initial outcomes, including increased social connections and self-efficacy, to participation in NORCs and NORC programs, only a few studies were longitudinal in design , making it difficult to identify intermediate outcomes. Those that were longitudinal in nature had mixed results: a longitudinal 5-year program evaluation of a single NORC by Elbert and Neufeld  found thGreenfield et al  include The framework developed by Greenfield et al  presentsThis is the first synthesis of the literature on NORCs and provides an important examination of how NORCS are described and the potential benefit of NORCs to older adults and communities. Since the 1980s, the body of literature around NORCs and NORC-SSPs has grown, as has the spread of the programs themselves. This scoping review yielded articles (n=64) that described NORCs and NORC programs across North America. Of the included articles, 94% (60/64) were written focusing on a US context. There is a notable absence of international perspectives in this body of research. However, we know that there is significant work looking at aging in the community that is being conducted in other countries; for example, cohousing work in the Netherlands ,71 and aIt is clear that, even in the similar North America context, there is a lack of consensus as to what specifically constitutes a NORC. Although the definition proposed by Hunt and Gunter-Hunt  was usedThe literature highlighted the importance of both external resources such as partnerships and internal resources such as staff and volunteers as being key to the success of a NORC-SSP. Multiple partners are important to the successful functioning of a program; notably, Blumberg et al  describeAuthors also described activities and services of NORC programs in detail and looked at both social programs and service delivery. These 2 categories of activities are cited in the conceptual framework developed by Greenfield et al  as critiThe literature included in this review also highlights the complexities around the funding and sustainability of NORC programs. A variety of means were used to fund NORC programs, including philanthropic and organizational grants, government funding, co-op board funding, membership fees, and annual fundraising. No single method seemed to be more sustainable than others, and as Greenfield and Frantz  reportedRegarding the impacts of NORCS, interestingly, health and well-being outcomes were reported primarily for NORC programs, aligning well with the conceptual framework developed by Greenfield et al ; howeverOn the basis of the findings from the literature, NORCs show great promise in initial outcomes that benefit the health and well-being of older adult participants. Although older adults in NORC programs demonstrated increased self- and collective efficacy and greater sense of community, increased social supports and reduced isolation, and self-reported access to support and reduced unmet needs, the research is largely descriptive. Although the purpose of this review was not to weigh the levels of evidence, it is clear that more robust study designs are needed. There are also significant gaps in the literature when looking at intermediate and long-term outcomes. Indeed, only a few articles  were longitudinal in nature, spanning a maximum of 5 years in study duration. Further research into NORC programs should look longitudinally at health and well-being outcomes to determine the long-term impacts of participating in a NORC program, including whether participation leads to an increased ability for an older adult to age in place. Longitudinal work should also explore organization-level benefits, including the journey of a NORC program to operational sustainability.There are clear challenges in conducting community-based research, and traditional randomized controlled trials may not be feasible to examine NORC outcomes. Other community models to support aging, including the village model in the United States ,74 and cRecent work by the Ontario COVID-19 Science Advisory Table demonstrates ways in which NORCs can be better used to support community-dwelling older adults; the Science Table’s members identified NORCs in Toronto, Ontario, Canada, a city of high COVID-19 incidence, for the purpose of rapidly facilitating community-based COVID-19 vaccination clinics ; yet, doSome authors of articles included in this review  described different engagement activities that sought to empower older adults living in NORCs. Research exploring the village model found that older adults are highly involved in the development of their programs, including policy development, governance, and actual service delivery . ResearcChallenges with sustainability, particularly related to funding, have also been reported in research conducted on the village model . UltimatThere was also a surprising lack of information surrounding the question of how much a NORC program costs to run annually. Although variation within different contexts would be expected, this information is critical to present to municipalities or other stakeholders who would be interested in the economic impacts of such a program to determine the budget allocation required to support such programs. In addition, details related to annual costs would help with planning new NORC communities. Further research should explore the cost breakdown of a NORC program and the cost-benefit of the model in comparison with other current means of supporting older adults, including home care and long-term care facilities.With our rapidly aging population, there is a clear need to consider how to support older adults living in communities. NORCs hold great promise and are a highly undeveloped approach to developing older adult communities. The body of research around NORCs and NORC programs has been growing for >30 years in North America, and this review provides a critical launching point to begin a focused program of research related to NORCS. NORC programs have the potential to leverage existing resources and partnerships for the purpose of supporting older adults to live well in the community. On the basis of this review, it is clear that further research needs to be conducted to more clearly define what constitutes NORCs and NORC programs, how to identify them in different contexts, and how to create an impact on older adults’ health and well-being over time.


The adsorptions of Cu2+ and Cd2+ on the OSP followed the pseudo-second-order kinetic model as well as the Temkin and Freundlich isotherm model. Comparatively, the adsorptions of heavy metal cations on the PVA-OSP followed the pseudo-first-order kinetic model as well as the Temkin and Langmuir isotherm model. In conclusion, this study showed that the PVA-OSP composite materials may be useful in the treatment of wastewater polluted by heavy metals.The accumulation of discarded mollusk shells has occupied a large land area and caused severe environmental pollution problems. Discarded mollusk shells are mainly composed of calcium carbonate and therefore can be used for the removal of heavy metals from the contaminated aquatic environment. Theoretically, shells with a smaller powder size have a higher adsorption capacity for heavy metal ions. However, the agglomeration and the outflow of small particles limit the applications of mollusk shells in water treatment practices. To overcome the shortcomings of mollusk shells in heavy metals adsorptions, a polymer composite material comprising poly /oyster shell powder (PVA-OSP) was prepared with the solution casting method for the adsorption of heavy metal ions from wastewater. The structures and the heavy metal adsorption properties of the oyster shell powder (OSP) and the composite PVA-OSP were studied and compared. Analysis results of XRD and FT-IR showed a successful combination of OSP and PVA by a chemical cross-linking modified with sodium silicate. The composite PVA-OSP has good thermal stability for common adsorption processes. The adsorption results showed that the adsorption capacity of the PVA-OSP composite for both Cu  •Modified shell composite overcomes shortcomings of oyster shell as an adsorbent.•Modified shell composite shows better removal efficiency for heavy metal pollution.•Combination of organic and inorganic matters may result in improvement in adsorption.•The reaction conditions for adsorbent composite production are mild. Poly; Oyster shell powder; Heavy metals; Adsorption; modification. Fossil fuel combustion, mining, smelting, material corrosion, waste disposal, and agricultural activities are the main anthropogenic sources of heavy metal pollution . Heavy mThe adsorption methods are simple, easy to operate, and have good treatment results . The selShellfish aquaculture is developing rapidly and the amount of waste shell generated from shellfish aquaculture is huge . Shell p2 nanocomposite was designed for the selective adsorption of methylene blue  (PVA) is a cheap, highly hydrophilic, non-toxic, and highly stable polymer with a three-dimensional network structure , which cene blue . PVA synand Cu2+ , 2017c. tal ions . The filtructure . As a ri2SiO3-mediated crosslinking for the first time. FT-IR, XRD, SEM, and TG-DSC were used to characterize the structural properties and thermal stability of the PVA-OSP composite. In addition, the adsorption properties and associated mechanisms of the composite and OSP were studied and compared by a batch adsorption experiment.To overcome the shortcomings of shells as adsorbent and realize the reasonable application of waste shells in the treatment of wastewater polluted by heavy metal, the PVA-OSP composite material was prepared by coating oyster shell powder (OSP) with PVA through Na22.1−1), copper chloride (purity: 99%), cadmium chloride (purity: 99%), and sodium silicate  were purchased from Sinopharm Chemical Reagent Co., Ltd., Shanghai, China. Oyster shells were obtained from Chengyang aquatic products wholesale market, Qingdao, Shandong Province, China.PVA  to pass a 200-mesh sieve (pore size is 74 μm). The sieved powders were ground again in an airflow pulverizer  to pass a filter bag of 10 microns. The oyster shell powders (OSP hereafter) were then oven-dried at 70 °C to constant weight and stored at room temperature for further use.A certain amount of dried PVA was soaked in deionized water for 24 h, then stirred and heated at 90 °C for dissolution. After the dissolving of PVA and naturally cooling, deionized water was added to make a 5 wt% PVA solution. Quantified OSP and sodium silicate were added into the PVA solution, which was then vigorously stirred at 90 °C for 2 h. After that, the mixtures were continuously stirred at room temperature for 2 h. Then, the mixed solution and pure PVA were poured into different Teflon petri dishes and dried at 40 °C for 24 h to obtain the solid PVA-OSP composite and the pure PVA film. Thin slices were cut from the composite with a sharp blade for further characterization and adsorption experiments.2.3−1 to 4000 cm−1. Thermoanalytical characterizations of materials were performed in nitrogen flow using a Simultaneous Thermal Analyzer  at 20 °C min−1 heating rate from 25 °C up to 800 °C. The surface morphologies of the materials were determined using a Field Emission Scanning Electron Microscope .The crystal structures data of the pure PVA, the OSP, and the PVA-OSP were collected by an X-Ray Diffractometer  with the scanning range 2θ = 10–80° and the scanning increment of 0.02°. The chemical structures of the samples were scanned by an FT-IR spectrometer , with frequencies ranging from 400 cm2.42+ and Cd2+ were set respectively to explore the static adsorption effect of adsorbents on heavy metal ions. Heavy metal ions were made in solution using CuCl2 and CdCl2, respectively.Different addition amounts of adsorbents, initial pH value, adsorption time, adsorption temperature, and initial concentration of Cu−1 heavy metal ion solution (pH was about 7). Solutions were allowed to stand for 24 h at 30 °C in an oven. The supernatants were taken for ion concentration measurement by ICP-OES . The same sampling and analysis methods were used for the following adsorption treatments. The initial adsorption pH value was adjusted by adding 0.1 mol L−1 hydrochloric acid or sodium hydroxide solution. The adsorbents (0.1 g) were added into heavy metal ion solution at different pH (2.0–8.0) for 24 h at 30 °C. Effect of contact time was conducted by adding 0.1 g of adsorbent into heavy metal solution (pH was about 7) at temperatures of 20 °C, 30 °C, and 40 °C. The supernatants were collected at 8 different time points within 24 h to analyze heavy metal concentrations, and the associated variations in concentration data were fitted to different kinetic models. For the thermodynamics adsorption study, the adsorbents (0.1 g) were added into 100 mL of individual heavy metal ion solutions with concentrations ranging from 25 to 200 mg L−1 at different temperatures  for 24 h. The adsorption isotherm data were fitted to different thermodynamics models.The amount effect of adsorbents was conducted by adding adsorbents ranging from 0.02 to 1 g into 100 mL of 50 mg Lqe is the adsorption capacity (mg g−1) of the adsorbents at adsorption equilibrium, C0 and Ce are the initial and equilibrium concentration of the ions (mg L−1), respectively, V is the initial volume of solution (L), and m is the weight of the adsorbents (g).The amount of heavy metal ions adsorbed to adsorbents was calculated using the following equation:33.1XRD patterns are performed on the materials of PVA, OSP, and PVA-OSP, respectively. Pure PVA exhibits characteristic crystalline peaks at 2θ values of 19.5°, and 40.5°, which are related to the semi-crystalline nature of PVA a. The se3 in the PVA-OSP material is highly similar to the standard card of calcite. The insertion of the OSP into the PVA matrix provided a few changes in the XRD pattern of PVA. A peak at 29.9° was observed as a result of the presence of OSP , ν2 (out-of-plane bending), and ν3 (asymmetric stretching) vibration modes of CO32− in the calcite form. Besides, the characteristic of overlapped peaks around 1795, 2512, and 2874 are also observed , C–H wagging vibration , C–H bending vibration (1419 cm−1vs. 1410 cm−1), C=C stretching vibration (1650 cm−1vs. 1648 cm−1), C=O stretching vibration (1733 cm−1vs. none) and C–H stretching vibration (2920 cm−1vs. 2917) are observed. In contrast to the OSP, in-plane bending vibration of CO32− , out-of-plane bending vibration (873 cm−1vs. 875 cm−1), asymmetric stretching vibration (1405 cm−1vs. 1410 cm−1), and overlapped peak  are shown. In addition, some new peaks appeared  at equilibrium and time t (min), respectively; k1 (min−1), k2 (g mg−1 min−1) and ki  was used for plotting and curve fitting to obtain each parameter.The adsorption kinetics is critical to determine the rate of heavy metals adsorption by PVA-OSP at different time intervals and to understand the associated adsorption mechanism. The kinetics of adsorption behaviors of heavy metals onto the PVA-OSP were analyzed by pseudo-first-order kinetics , pseudo-ntercept . Adsorptqe of the OSP increases rapidly in the first 180 min (R2) of the pseudo-second-order model fits of Cu2+ and Cd2+ adsorption onto OSP were higher than the corresponding coefficients from the fits by the pseudo-first-order kinetic model. The qe, cal (mg g−1) values obtained from the pseudo-second-order kinetic model were closer to the qe, exp (mg g−1) values in K) indicate a faster rate of adsorption of the heavy metal ions compared to smaller values. The adsorption rate of Cu2+ was faster than the adsorption rate of Cd2+. Thus, the adsorption process suggests that the adsorption of Cu2+ and Cd2+ by the OSP can be rationally assessed by the pseudo-second-order model. In contrast, the correlation coefficients of the PVA-OSP display close evaluated qe, exp (mg g−1) values and good fitness with the experimental qe value from the pseudo-first-order kinetic model than the second-order equation. The adsorption of Cu2+ by the PVA-OSP was still faster than the adsorption of Cd2+ according to the experimental data  which could be obtained with KL is the Langmuir adsorption constant (L mg−1), qm is the maximum amount of adsorption corresponding to complete monolayer coverage on the surface (mg g−1), and Ce is the equilibrium concentration of heavy metal ion solution (mg L−1).The adsorption isotherm data could describe adsorption capacity, surface properties, and affinity of the adsorbents, and help to understand the mechanism of heavy metal ions adsorption onto the adsorbents. The experimental data were examined by Langmuir, Freundlich, and Temkin models for the OSP and PVA-OSP composite. The Langmuir model, shown in KF is the adsorption constant for the adsorption capacity (mg g−1), and The Freundlich model, shown in T is the absolute solution temperature (K), R is the universal gas constant (8.314 J mol−1 K−1), and KT (L mol−1) is the Temkin equilibrium binding constant corresponding to the maximum binding energy. The variation of adsorption energy bT (J mol−1) is a constant related to the heat of the adsorption process, where the positive or negative value of bT shows that the adsorption process is an endothermic or exothermic process, respectively.The Temkin model, shown in Ce as abscissa and qe as ordinate. Sigmaplot was also used for plotting and curve fitting to obtain each parameter. With the increase of temperature, the adsorption capacity of the OSP , a constant related to the heat of the adsorption process, indicates that the adsorption of different heavy metal ions by both the OSP and the PVA-OSP is an endothermic process  components but also had good thermal stability. According to the results, the pseudo-first-order kinetic model as well as the Temkin and Langmuir isotherm model exhibited well fitness with the experimental data achieved from isotherm and kinetic studies with the PVA-OSP. Contrastingly, the pseudo-second-order kinetic model as well as the Temkin and Freundlich isotherm model fitted the isotherm and kinetic data of the OSP better. The adsorption capacities of Cu2+ and Cd2+ onto the PVA-OSP composite were about 6.64 and 7.83 times the adsorption capacities of the OSP on average, respectively, according to the fitting of the thermodynamic data by the Langmuir model. It indicates that the modified shell material can play a better role in adsorption. Good dispersion of OSP in the composite and the high hydrophilicity of PVA-OSP improve pore diffusion obstruction of heavy metals in the composite material. The composite material developed in this study, which ameliorates agglomeration and loss of powders, could be a good candidate material for the treatment of wastewater caused by heavy metal pollution. Based on the preparation method proposed in this paper, the optimization of the preparation method, composition ratio and adsorption selectivity of heavy metals can be further studied in the future.The PVA-OSP porous composite with potential applications in the removal of heavy metal ions from wastewater was first prepared in this study. The structure and thermal analyses of the produced composite confirmed that not only was the occurrence of interactions between organic (PVA) and inorganic (Na2+ and Cd2+ were respectively taken as the treatment objects. The actual wastewater generally contains a variety of heavy metal ions and other pollutants, which may form a complex system of competitive adsorption. To realize the practical application of the adsorbent, further research should be conducted on the removal of pollutants in the complex system.It should be noted that this study had been primarily concerned with the feasibility of the PVA-OSP composite adsorption of heavy metals and did not include the optimization of the preparation method and composition ratio of this material. Besides, single CuZhenfeng Zhou: Conceived and designed the experiments; Contributed reagents, materials, analysis tools or data; Wrote the paper.Yinuo Wang; Shu Sun; Yicheng Wang: Performed the experiments; Analyzed and interpreted the data; Wrote the paper.Liang Xu: Conceived and designed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.10.13039/100006190Research and Development Project of Ningxia Hui Autonomous Region [2021BEG03013], 10.13039/501100001809National Natural Science Foundation of China [41601339].This work was supported by the Key Data included in article/supp. material/referenced in article.The authors declare no conflict of interest.No additional information is available for this paper.


Infectious Diseases of Poverty [Global Report for Research on Infectious Diseases of Poverty [Infectious Diseases of Poverty.Exactly 10 years ago, on 25 October 2012, a group of scientists, policy-makers, and practitioners undertook an ambitious project to launch a new open-access journal, named The aim of the new journal was to publish a blend of original research articles and more empirical work, the latter embracing different types of articles, including scoping reviews, case studies, opinion pieces, and policy briefs. Its focus was to be on infectious diseases of poverty, coinciding with the launch of WHO’s first roadmap to overcome the global impact of neglected tropical diseases (NTDs) earlier that year , and undInfectious Diseases of Poverty, provides a juncture to review the relationship between the scope of publications and the journal’s impact. During the last decade, the journal has endorsed and promoted the One Health discipline, which has evolved from concept to practices [One World, One Health Conference formulating the Manhattan principles in 2004, to the action plan that has been formulated by four international organizations, namely the Food and Agriculture Organization of the United Nations (FAO), the World Organisation for Animal Health (WOAH/OIE), the United Nations Environmental Programme (UNEP), and WHO. Over the years, the number of publications and their citations of One Health research has grown considerably [The event to celebrate the 10th anniversary of continuous publication of the journal, ractices , and froiderably . In paraInfectious Disease of Poverty has been climbing up as well, exceeding 10 in 2021 with an H-index of 47, according to the Web of Sciences (accessed on 6 October 2022). Importantly, the journal continues to engage participants from the low- and middle-income countries (LMICs) in the leadership, management and dissemination of its outputs. These developments are complemented by a series of remarkable milestones  fora.Thirdly, the journal has made efforts to disseminate seminal research findings by 18 international channels, such as e-mail campaigns, editor picks, landing pages, cross-journal promotion, among others. This has substantially improved the visibility of the journal, the articles, and the authors of the respective papers. Multidisciplinary topics and promotional efforts have made the journal a reputable and valued academic platform for scientists, policy-makers, professionals, and students in the field of infectious diseases and One Health. As of September 2022, the journal has published 1060 papers by 5298 authors from 108 countries, that were downloaded over 4.7 million times. Such a huge amount of dissemination has facilitated collaboration between scientists worldwide. Yet, an analysis of authors’ cross-country collaborations has shown that the People’s Republic of China, the United States of America, the United Kingdom, Switzerland, and European countries still constitute most of the research-centres of collaboration in the field of infectious diseases of poverty, and that much more remains to be done to foster key competencies to conduct programmes from tropical and sub-tropical regions (Fig. As programmes to prevent, control, and eliminate infectious diseases of poverty have considerably been hampered by the COVID-19 pandemic with an estimated delay in the realization of the SDGs by 2030 , the jou


Allium cepa L. Etoxazole solutions were applied to three groups formed from A. cepa bulbs at 0.125 mL/L, 0.25 mL/L and 0.5 mL/L doses, respectively. The control group was treated with tap water throughout the experimental period. The toxic effects of Etoxazole became more apparent as the dose of Etoxazole was increased. The growth-limiting effect was most pronounced in the highest dose group with approximately 29%, 70% and 58.5% reductions in germination percentage, root elongation and weight gain, respectively. The genotoxic effect of Etoxazole was most severe in the 0.5 mL/L dose group. In this group, the mitotic index decreased by 30% compared to the control group, while the micronucleus frequency increased to 45.3 ± 3.74. The most observed aberrations were fragment, vagrant chromosome, sticky chromosome, unequal distribution of chromatin, bridge, reverse polarization and nucleus with vacuoles. The malondialdehyde level showed a gradual increase with increasing Etoxazole doses and reached 2.7 times that of the control group in the 0.5 mL/L Etoxazole applied group. Catalase and Superoxide dismutase activities increased in the groups exposed to 0.125 mL/L and 0.25 mL/L Etoxazole with dose dependence and decreased abruptly in the group treated with 0.5 mL/L Etoxazole. Etoxazole triggered meristematic cell damages, such as epidermis cell damage, thickening of cortex cell walls, flattened cell nucleus and indistinct transmission tissue. Considering the versatile toxicity induced by Etoxazole, we announce that this chemical has the potential to cause serious damage to non-target organisms. It should be noted that the higher the dose of exposure, the more severe the level of damage. This study will be an important reminder to limit the indiscriminate use of this highly risky agrochemical.Etoxazole is among the systemic pesticides with acaricidal and insecticidal characteristics. This paper reports the first evaluation of the toxic effects of Etoxazole on  Pesticides are chemical and natural substances administered to control or kill pests, including insects, herbs, rodents, arthropods and nematodes that cause plant diseases, yield losses and health problems2. Due to the widespread use of pesticides in many agricultural industries, high levels of agricultural production and quality have been achieved. In addition to nourishing and multiplying crop yield, pesticides have other benefits, such as saving time and effort3. Despite all their advantages, pesticides, most of which are hydrophilic, tend to accumulate in nature as potential pollutants and harm non-target organisms4. Common classifications of pesticides are based on the target pest.The main threats to agriculture and forestry around the world are pest-related plant diseases5. It was first introduced to the public as a new option to carbamates, pyrethroids, organophosphates and organochlorines in 1994 and took its place in the market as an acaricide/insecticide in 19986. Since that time, it has been utilized to eliminate the eggs, larvae and nymphs of mites including Tetranychus spp., Eotetranychus spp. and Panonychus spp. on fruits such as grapes, strawberries, nuts, citrus and cotton7. Pest management achieved by Etoxazole also includes limiting damage from rice green leafhopper (Nephotettix nicropictus) and diamondback moth (Plutella xylostella) infestations8. Etoxazole inhibits chitin biosynthesis by binding to the sulfonylurea receptor and prevents moulting9. Chang et al.5 investigated the systemic stereoselectivity of Etoxazole in grapes, strawberries and apples to estimate residue-induced toxicity in humans and the environment. Due to its 20-day half-life, Etoxazole residues can be easily transported to humans and animals. According to EFSA10, Etoxazole can be accepted as bio-accumulative, persistent and toxic. It has been reported that Etoxazole induces toxic effects such as neurotoxicity, genotoxicity, cytotoxicity, infertility, endocrine disrupting activity and oxidative stress on various non-target organisms16. In zebrafish (Danio rerio) larvae, Park et al.4 discovered that Etoxazole caused developmental abnormalities, hearth rate disorders and reduced viability. In the study of Ham et al.9, it was indicated that Etoxazole exposure induced testicular toxicity arisen from mitochondrial failures and altered gene expression in mice. Etoxazole-induced genotoxicity in human peripheral lymphocytes was evidenced by an increase in chromosome abnormalities and a decrease in mitotic division11. The European Union banned the use of Etoxazole in 2018 because of its persistence in soil sediments and toxicity17.Pesticides used to combat mite populations include chemicals with acaricidal/insecticidal properties. Etoxazole, a diphenyl oxazoline miticide, is chemically known as 2--4-[4--2-thoxyphenyl]-4,5-dihydrooxazoleAllium cepa test system is well suited for determining the cytotoxicity and genotoxicity of pesticides. As a short-term indicator, it allows assessing the score of the mitotic index (MI), the frequencies of micronuclei (MN) and aberrant chromosomes (ACs), as well as the levels of oxidative stress and growth18. The most important merit of this test system is that the results obtained from the A. cepa assay have an extremely high correlation with analyses in mammals19.The overuse of pesticides raises concerns about their safety. There are many eukaryotic bioassay methods used to evaluate pesticide-induced toxicity in non-target biota. With its large chromosomes (2n = 16) and rapid root growth, the A. cepa to Etoxazole. For this purpose, physiological , genotoxic  and biochemical catalase (CAT: EC 1.11.1.6) and (superoxide dismutase (SOD: EC 1.15.1.1) activities and malondialdehyde (MDA) accumulation effects in Etoxazole-treated A. cepa were evaluated. Moreover, the types of cellular damage induced by Etoxazole in meristematic tissue were analyzed.In the literature, there is a data gap in the field reporting the multifaceted toxic effects of Etoxazole applications on plants, apart from residue analyses. Therefore, the object of the present study was to determine the biological responses of A. cepa bulbs obtained commercially from Şebinkarahisar district of Giresun province were classified in the laboratory based on their size. The bulbs with the closest initial weights to each other were selected for the study. Four groups (each containing 50 bulbs) were formed. Aqueous solutions of Etoxazole were prepared from the commercial preparation with the trade name Delos  containing 110 g/L Etoxazole as the active ingredient. Etoxazole solutions were applied to the three treatment groups at doses of 0.125 mL/L, 0.25 mL/L, and 0.5 mL/L, respectively. In the selection of Etoxazole concentrations, the application dose recommended by the manufacturer, and half and twice this dose were used. On the other hand, the control group was treated with tap water during the experiment. All treatments were carried out by placing the onion stems in glass tubes in contact with the relevant solution to allow the emergence of fresh adventitious roots. The solutions were regularly refreshed every day. The application of pesticide solutions was carried out in a dark room at a constant temperature (23 ± 2 °C) for 3 days. In order to investigate Etoxazole toxicity, multifaceted analyses were performed in A. cepa . To observe the rooting percentage, 50 bulbs from each group (n = 50) were taken into account.All bulbs were weighed (g) before administration of the relevant solutions and after 72 h of treatment. The weight recorded before the applications was subtracted from the second weight to calculate the total weight increase of the bulbs.At the end of the experiment, the length of the roots (cm) from the apex of the root cap to the root primordial was measured with a ruler to evaluate root elongation. For root elongation and weight gain, 10 randomly selected bulbs from each group (n = 10) were analyzed.20. Root tips were placed in Clarke’s fixator consisting of glacial acetic acid and ethanol (3:1) for 120 min following the harvest. Root materials were then hydrolyzed in a 1 N HCl solution at 60 °C for 12 min. A 1% acetocarmine solution freshly prepared in 45% acetic acid was utilized to stain root tips for 24 h. Microscopic preparations were formed by gently crushing root materials with a drop of 45% acetic acid under a coverslip. For genotoxicity analyses, 10 slides were prepared from each group. MI analysis was performed by screening 10,000 randomly selected cells from these slides (1000 cells per slide). On the other hand, MN and ACs were evaluated by screening 1000 randomly selected cells from the same slides (100 cells per slide). MN existence was evaluated using the features previously noted by Fenech et al.21. All slides were screened under a research microscope  with a magnification of X 500.Genotoxicity measurements, including MI, MN and ACs analyses, were carried out by microscopic examination of decapitated root tip preparationsIn order to determine the biochemical changes caused by Etoxazole applications, the MDA level and the activities of CAT and SOD enzymes were investigated.22. 0.1 g of root tip material was mixed with 1 ml of sodium phosphate buffer after it was thoroughly ground by adding liquid nitrogen to it. The pH of the buffer was adjusted to 7.8 before the buffer (50 mM) was used. The homogenates were immediately centrifuged at 14,000 rpm at 4 °C for 20 min, and the upper fraction (the supernatant containing the enzyme) was stored in a deep freezer at − 80 °C.The extraction of antioxidant enzymes was performed according to Zou et al.23. Firstly, 1.5 mL of sodium phosphate buffer at 0.2 M concentration and 7.8 pH was taken into a tube. The buffer was mixed with hydrogen peroxide (0.1 M) and distilled water. The reaction was started by adding the enzyme-containing buffer (0.2 mL) to the mixture. CAT activity was calculated as OD240 nm minute per g of fresh weight (OD240 nm min/g FW) by monitoring the absorbance, showing the decrease in hydrogen peroxide concentration at 240 nm wavelength. The whole procedure was repeated 10 times (n = 10).The catalytic activity of the CAT enzyme was assessed according to the analysis method of Beers and Sizer24. Firstly, 1.5 mL of sodium phosphate buffer at 0.05 M concentration and 7.8 pH was taken into a tube. Distilled water, EDTA-Na2 (0.1 mM), riboflavin (20 μM), methionine (130 mM), nitro blue tetrazolium chloride (750 μM) and polyvinylpyrrolidone (4%) were added to the buffer-containing tube. Finally, 0.01 mL of enzyme-containing buffer, which was dissolved by holding the tubes in the palm of the hand without shaking, was added to this mixture. For the initiation of enzyme activity, the mixtures were exposed to fluorescent light of 375 μmol/m2/s intensity for 15 min. SOD activity was calculated as a unit per mg of fresh weight (U/mg FW) by reading the absorbance of the samples at 560 nm wavelength. The whole procedure was repeated 10 times (n = 10).The catalytic activity of the SOD enzyme was assessed according to the analysis method of Beauchamp and Fridovich25. 0.4 g of root tip material was ground in a mortar containing 8 mL of trichloroacetic acid (5%). Following the homogenization completed at room temperature, the samples were centrifuged at 12,000 rpm for 15 min in a centrifuge at 23 °C. The upper fraction of the homogenates was collected and added to the premixed trichloroacetic acid (20%) and thiobarbituric acid (0.5%). After allowing the reaction to proceed at 90 °C for 40 min, the reaction was stopped by placing the tubes on ice. A second centrifugation process  was applied to obtain the supernatant fraction. The MDA levels of the samples were calculated as μM per g of fresh weight (µM/g FW) by recording the absorbance of the supernatant fractions at 532 nm wavelength. The whole procedure for MDA determination was repeated 10 times (n = 10).MDA accumulation, which is a common marker of peroxidation of the lipids in cellular membranes, was analyzed according to Unyayar et al.Meristematic cell damages triggered by Etoxazole applications were assessed in the cross-section of the roots taken from the root tips, excluding the cap part. Roots were carefully washed to remove pesticide residues before sections were prepared. Two drops of methylene blue (3%) were used to stain the cells. In order to analyze meristematic abnormalities, slides were screened under a research microscope  with × 500 magnification. Three severity classes were used to express the frequency of occurrence of damage types: absent, minor, moderate and major.p < 0.05) between the mean values. Results were arranged to specify “mean value + standard deviation”.One-way ANOVA and Duncan’s test were implemented to determine the statistical significance  was a sign that the membranes were damaged due to oxidative stress, although the defense mechanism against this stress was activated. While MDA continued to accumulate in the HLE group, enzyme activities began to be restricted; this may indicate that the enzymatic antioxidant defense mechanism of cells is no longer able to overcome oxidative stress conditions. This is the first study to demonstrate Etoxazole-induced oxidative stress in plants. Synchronized increase of oxidative stress and genotoxic damage in Etoxazole applied A. cepa revealed an “Etoxazole-mediated genotoxicity—oxidative stress relationship”. As a matter of fact, the increased production of reactive molecules in plant cells under the influence of agrochemicals, including pesticides, causes genotoxicity as well as oxidative stress as it damages vital elements in cells such as proteins, membranes and nucleic acids56.Abnormal circumstances may give rise to the over-production of superoxide anion and hydrogen peroxideA. cepa roots (Table A. cepa59. Deformations in epidermis cells can be considered as a precaution taken by plants to prevent the uptake of pesticides into cells. Cells that encounter pesticides seem to be squeezed, possibly to keep the contaminant out. Thickening of the cortex cell walls can be accepted as a similar defense. On the other hand, the pesticide, which was inevitable to reach the inner parts of the cells, caused deformity in the cell nucleus and defects in the conducting tissue. Membrane disorders, as evidenced by increased MDA levels, probably allowed toxic chemicals to ruin the integrity of tissues59. Furthermore, these anatomical changes in the structure of the root meristems may have impeded the transport of water from the environment to the cells, ultimately leading to a limitation in plant growth and germination60.Etoxazole treatments induced a variety of meristematic cell damages, including epidermis cell damage, thickening of cortex cell walls, flattened cell nucleus and indistinct transmission tissue in ts Table , Fig. 5.Table A. cepa, which is a very popular organism for toxicity studies, were revealed for the first time from a multidimensional perspective. Physiological and genotoxicity parameters showed that Etoxazole suppressed growth, limited cell proliferation and increased the frequencies of MN and ACs. Considering growth arrest and alterations of the levels of genotoxicity indicators, Etoxazole harms the non-target systems in a dose-related way. In addition, study data revealed that Etoxazole is a trigger of oxidative stress as well as a genotoxicity initiator in A. cepa. Although the enzymatic antioxidant system was activated following Etoxazole treatments, SOD and CAT activities were significantly reduced due to the highest dose of Etoxazole. Meanwhile, lipid peroxidation continued to elevate due to increasing Etoxazole doses. Furthermore, Etoxazole provoked an apparent deterioration in meristematic cell integrity in roots. All in all, Etoxazole harms non-target systems in a dose-dependent way, considering the results of all the parameters. It should not be forgotten that all biota is at risk and the fate of the environment is in our hands (Indiscriminate application of agrochemicals leads to a huge pollution of nature. Due to pesticides accumulating in the environment, many non-target organisms become “toxicity targets”. In this study, the dose-related toxic effects of Etoxazole in ur hands . More coSupplementary Information.