Concerning eRGD, predictive accuracy of all analyzed serological markers was moderate . Additionally, multivariable analysis identified previous dialysis/no preemptive transplantation (OR 2.4 (95% CI: 1.41–4.01), p = 0.021), donor age (OR 1.07 (95% CI: 1.03–1.14), p < 0.010), donor body mass index (OR 1.32 (95% CI: 1.01–1.072), p = 0.04), donors cerebrovascular cause of death (OR 7.8 (95% CI: 2.21–26.9), p < 0.010), donor length of ICU stay (OR 1.27 (95% CI: 1.08–1.49), p < 0.010), as well as CIT pancreas (OR 1.07 (95% CI: 1.03–1.14), p < 0.010) as clinical relevant prognostic predictors for ePGD. Further, a peak of lipase (OR 1.04 (95% CI: 1.02–1.07), p < 0.010), peak of CRP levels (OR 1.12 (95% CI: 1.02–1.23), p < 0.010), pancreatic serum lipase concentration on POD 2 > 150 IU/L (OR 2.9 (95% CI: 1.2–7.13), p = 0.021) and CRP levels of ≥ 180 ng/mL on POD 2 (OR 3.6 (95% CI: 1.54–8.34), p < 0.01) and CRP levels > 150 ng/mL on POD 3 (OR 4.5 (95% CI: 1.7–11.4), p < 0.01) were revealed as independent biochemical predictive variables for ePGD after transplantation. Conclusions: In the current study, the combination of peak lipase and CRP levels were highly effective in predicting early pancreatic graft dysfunction development following SPKT. In contrast, for early renal graft dysfunction the predictive value of this parameter was less sensitive. Intensified monitoring of these parameters may be helpful for identifying patients at a higher risk of pancreatic ischemia reperfusion injury and various IRI- associated postoperative complications leading to ePGD and thus deteriorated outcome.Background: Despite recent advances and refinements in perioperative management of simultaneous pancreas–kidney transplantation (SPKT) early pancreatic graft dysfunction (ePGD) remains a critical problem with serious impairment of early and long-term graft function and outcome. Hence, we evaluated a panel of classical blood serum markers for their value in predicting early graft dysfunction in patients undergoing SPKT. Methods: From a prospectively collected database medical data of 105 patients undergoing SPKT between 1998 and 2018 at our center were retrospectively analyzed. The primary study outcome was the detection of occurrence of early pancreatic graft dysfunction (ePGD), the secondary study outcome was early renal graft dysfunction (eRGD) as well as all other outcome parameters associated with the graft function. In this context, ePGD was defined as pancreas graft-related complications including graft pancreatitis, pancreatic abscess/peritonitis, delayed graft function, graft thrombosis, bleeding, rejection and the consecutive need for re-laparotomy due to graft-related complications within 3 months. With regard to analyzing ePGD, serum levels of white blood cell count (WBC), C-reactive protein (CRP), procalcitonin (PCT), pancreatic lipase as well as neutrophil–lymphocyte ratio (NLR) and platelet–lymphocyte ratio (PLR) were measured preoperatively and at postoperative days (POD) 1, 2, 3 and 5. Further, peak serum levels of CRP and lipase during the first 72 h were evaluated. Receiver operating characteristics (ROC) curves were performed to assess their predictive value for ePGD and eRGD. Cut-off levels were calculated with the Youden index. Significant diagnostic biochemical cut-offs as well as other prognostic clinical factors were tested in a multivariate logistic regression model. Results: Of the 105 patients included, 43 patients (41%) and 28 patients (27%) developed ePGD and eRGD following SPKT, respectively. The mean WBC, PCT, NLR, PLR, CRP and lipase levels were significantly higher on most PODs in the ePGD group compared to the non-ePGD group. ROC analysis indicated that peak lipase (AUC: 0.82) and peak CRP levels (AUC: 0.89) were highly predictive for ePGD after SPKT. The combination of both achieved the highest AUC (0.92;  Ischemia reperfusion injury (IRI) is a major cause for early graft damage, which ultimately results in severe patient morbidity and mortality in solid organ transplantation ,2.The pancreatic allograft is particularly susceptible for injuries in the early reperfusion period, which among other serious complications lead to damaging effects on the grafts’ microvasculature as well as dysfunction in both, the endocrine and exocrine pancreas . NotablyOf all solid organ transplantations, the pancreas graft is still most prone to development of early pancreatic graft dysfunction (ePGD), mainly induced by IRI, despite recent advances in surgical and procedural technologies, including machine perfusion instead of cold graft storage as well as refinements in immunosuppressive medications ,11,12,13Therefore, the goal of our current study was to evaluate and define predictive laboratory markers in clinical practice for the development of early  graft dysfunction in patients undergoing SPKT. Secondarily, these biomarkers were tested in combination with other known clinical factors as predictors of severity for ePGD and its application as useful biomarkers for clinical practice.The study protocol was approved by the local ethics committee of the University of Leipzig [AZ: Nr: 111–16-14032016]. From a prospectively collected electronic database, we retrospectively analyzed medical data on all patients undergoing SPKT at the University Hospital of Leipzig between 1998 and 2018. A special focus was set on the evaluation of different biochemical serum markers for their predictive value for early pancreatic graft dysfunction and renal graft dysfunction as well as graft function and outcome following SPKT.Patients younger than 18 years, those receiving kidney transplantation alone (KTA), those receiving pancreatic re-transplantation and patients with insufficient/missing data about perioperative, intraoperative and postoperative clinical and laboratory status and outcome were excluded.Standard demographic and clinicopathological characteristics were collected and analyzed before, at the time of and after transplantation as well as in the follow-up period for each patient. Pre-transplantation data included recipient and donor characteristics such as age, sex, body mass index (BMI), donor causes of death and donor’s comorbidities and clinical course , cardiopulmonary resuscitation). Furthermore, recipient data comprised the history and duration of diabetes mellitus, time on waiting list, pre-transplantation dialysis, endocrine metabolism and information on special comorbidities , blood pressure parameters and arterial hypertension as well as the number of antihypertensive agents). Peri- and postoperative data included information on peri- and postoperative clinical course  mismatches, cytomegalovirus (CMV) state, induction therapy) as well as patient and graft function and outcome. As a primary outcome parameter, the occurrence of early pancreatic graft dysfunction (ePGD) was evaluated which was defined according to previous definitions from literature ,18,19 asFor the evaluation of a possible predictive value for ePGD, different serum biomarkers were measured and compared between patients with ePGD and those with no ePGD.Herein, serum samples were analyzed preoperatively and at postoperative days (POD) 1, 2, 3 and 5 after transplantation. The serum panel included standard inflammation and pancreas markers such as white blood cell count , C-reactive protein , procalcitonin , serum lipase (IU/L) as well as a differential blood count to calculate the neutrophil–lymphocyte ratio (NLR) and platelet–lymphocyte ratio (PLR). Peak levels of C-reactive protein and serum lipase were also analyzed and defined as the highest serum levels within the first three days after transplantation.As described previously, pancreas and kidney grafts were procured and transplanted following the international standards and guidelines ,25,26,27The immunosuppressive protocol consisted of an induction therapy followed by triple maintenance therapy as described previously. Shortly, for induction therapy, antithymocyte globulin  or the interleukin-2 receptor antagonist basiliximab was used. Maintenance therapy included calcineurin inhibitors (CNI) (Cyclosporin or Tacrolimus), and/or antimetabolites (Sirolimus or Mycophenolate Mofetil (MMF)), and tapered steroids ,28.t-test, χ2, analysis of variance (ANOVA), Kruskal–Wallis and Wilcoxon–Mann–Whitney test.With regard to baseline data, continuous variables are reported as mean values with standard deviation, whereas categorical variables are presented as whole numbers and percentages (%). For the analysis of baseline data, we used the appropriate statistical significance tests, including Student’s To evaluate the predictive value and prognostic accuracy of the different biomarkers and clinical variables in the prediction of ePGD and eRGD, receiver operating characteristic (ROC) curves were generated, and the area under the curve (AUC) was calculated. To this end, AUCs ≥ 0.7 were defined as acceptable, AUCs ≥ 0.8 were defined as excellent and AUCs ≥ 0.9 were defined as exceptional biomarkers . The optp-value. A p-value < 0.05 was considered statistically significant. To determine the goodness-of-fit of the regression model, the Hosmer–Lemeshow-test (HLT) was used. The model was considered fit when p > 0.05 in HLT.The investigation of potential clinical prognostic factors for ePGD was further carried out using logistic regression analysis. In the final multivariable model, potential risk factors with significant values in univariate analysis and/or known risk factors from the literature were selected using the backward stepwise selection procedure with adjustment for potential confounders. Results of the regression analyses were presented as odds ratio (OR) with 95% confidence interval (CI) and its corresponding All statistical analyses were performed using the SPSS software .During the study period, a total of 105 SPKTs were performed and included in the current study. In total, 58 of the recipients were male and 47 were female with a mean age of 42.9 +/− 9.1 years.Among our cohort, 43 patients (41%) and 28 patients (27%) developed ePGD and eRGD following SPKT, respectively. The mean follow-up period of the study was 151 ± 34.4 months.p = 0.018) and after cardiopulmonary resuscitation (p = 0.06). Donor age (p = 0.02), donor BMI (p < 0.01) as well as donor ICU-LOS (p = 0.03) were increased in patients with ePGD compared to those without. Patients with ePGD were older with a mean age of 46.1 +/− 8.6 years versus 40.9 +/− 8.7 years without ePGD (p < 0.01) and showed a higher presence of peripheral arterial disease (p = 0.08).Donor and recipients’ demographic and clinico-pathologic baseline characteristics with regard to patients with or without ePGD are given in p = 0.01) as well as mean length of the hospital stay  were increased compared to those without ePGD. Furthermore, in patients with ePGD the occurrence of renal delayed graft function (eRGD+: 11 (26%) versus eRGD-: 7 (11%); p = 0.049) and early renal graft dysfunction (eRGD+: 16 (37%) versus eRGD-: 12 (19%); p = 0.039) were more common. No significant differences were observed with regard to kidney CIT (p = 0.194), mean warm ischemic time (WIT) of the pancreas (p = 0.225) or the kidney (p = 0.454), respectively, the operating time (p = 0.808) as well as the incidence of CMV infections (p = 0.427).p < 0.05; Pre- and postoperative trends of inflammatory markers and pancreatic enzyme serum levels in patients with and without ePGD are given in The AUC, cut-off values such as specificity and sensitivity of each analyzed biochemical marker including CRP, serum lipase, PCT, WBC, PLR and NLR levels for ePGD as well as for eRGD were determined using ROC analysis and listed in p < 0.01) with an ideal cut-off of 168 IU/L , and the AUC for peak CRP was 0.87  with an ideal cut-off 131 ng/mL   with a valid goodness-of-fit test  , whereas the accuracy of peak CRP and serum lipase levels were excellent (AUC > 0.8). As depicted in ctively) . When pee: 3.21) C. On thep < 0.01), time on dialysis pre-transplant (p = 0.016), no pre-emptive transplantation (p = 0.027), donor age (p = 0.02), donor BMI (p > 0.01), donor cerebrovascular disease as cause of donor death (p < 0.01), donor length of ICU stay (p = 0.038), cold ischemia time of the pancreas graft (p = 0.013), peak CRP levels (p < 0.01), peak serum lipase level (p< 0.01), serum lipase level on POD 1 > 220 IU/L (p < 0.01) and on POD 2 > 150 IU/L (p < 0.01) as well as serum CRP level of 180 ng/mL or greater on POD 2 (p < 0.01) and >150 ng/mL on POD 3 (p < 0.01).The relationship between preoperative characteristics, intraoperative factors, postoperative biochemical markers and the development of ePGD following SPKT is shown in p = 0.021), increased donor age (OR 1.07 (95% CI: 1.03–1.14), p < 0.010), donor BMI (OR 1.32 (95% CI: 1.01–1.072), p = 0.04), donor cerebrovascular disease as the cause of death (OR 7.8 (95% CI: 2.21–26.9), p < 0.01), donor length of ICU stay (OR 1.27 (95% CI: 1.08–1.49), p < 0.01) and CIT of the pancreas graft (OR 1.07 (95% CI: 1.03–1.14), p < 0.01) could be identified as independent clinical factors associated with increased ePGD following SPKT. Additionally, the following biochemical serum markers including the peak of serum CRP levels (OR 1.12 (95% CI: 1.02–1.23), p < 0.01), peak of serum lipase levels (OR 1.04 (95% CI: 1.02–1.07), p < 0.01), serum lipase concentration on POD 2 > 150 IU/L (OR 2.9 (95% CI: 1.2–7.2), p = 0.021) and serum CRP levels of ≥180 on POD 2 (OR 3.6 (95% CI: 1.54–8.34), p < 0.01) and >150 ng/mL on POD 3 (OR 4.5 (95% CI: 1.7–11.4), p < 0.01) were revealed as independent predictive factors for ePGD after SPKT. HLT shows a valid goodness-of-fit of the logistic regression model .In multivariable analysis see , no pre-Ischemia reperfusion injury (IRI) and subsequent early graft dysfunction play a central role for early as well as long-term outcome and graft function, not only in pancreas transplantation ,2. Well-Despite constant improvement in the field of SPKT, the pancreas graft especially remains highly prone to IRI and early graft dysfunction, which leads to early graft damage and consecutively severe patient morbidity and mortality. Due to the high susceptibility of the pancreas graft, unavoidable procedural and surgical steps during the process of transplantation may lead to considerable damage of the graft and impaired outcome ,31,32.In this context, the pancreatic allograft is particularly susceptible to injuries in the early reperfusion period with damaging effects on the grafts’ microvasculature resulting in early and severe post-transplant pancreatitis as well as the formation of thromboses in the pancreas vein, in some cases within a few hours after transplantation ,15,33. TMonitoring of serum biomarkers, repeated imaging studies and implementation of clinical scoring systems are widely used for the assessment of mortality and severity of acute pancreatitis in the non-transplant setting ,36,37,38In the past, serum CRP and interleukin levels have been well evaluated for the assessment of the severity and prognosis of acute pancreatitis in “non-transplant” patients ,16,38. RTransient elevation of serum pancreatic enzymes in the early postoperative period after SPKT is more common and generally caused by IRI and ePGD, which could reflect the degree of graft-related complications including pancreatitis ,40,41. IBased on these former findings and particularly with regard to the results of our ROC analyses, we believe that the combination of monitoring peak serum CRP and serum lipase levels during the first three to five days after SPKT may be very useful for the monitoring of ePGD-associated complications as well as in the prediction of early graft function and long-term outcome in SPKT recipients.In contrast, the ability of WBC as well as PLR and NLR to predict ePGD and pancreas graft-associated complications as well as early renal graft dysfunction in our patient cohort was assessed as fair. Our current findings are consistent with previous studies in the non-transplant setting, showing weak or acceptable predictive values of PLR and/or NLR for prediction of postoperative pancreas-related complications following pancreatic surgery as well as a reduced ability for the prediction of the severity of the disease in acute pancreatitis ,37,43,46In question of our results concerning serum PCT values, this marker is widely reported as a useful biomarker to differentiate sepsis- and non-sepsis-related inflammatory response and to predict severe bacterial infection as well as to guide discontinuation of antibiotic treatment. The role of PCT and its ability to predict disease severity as well as reliable prognosis in acute pancreatitis in the non-transplant setting, is a matter of dispute . So far,Current literature provides only sparce evidence for organ-specific biomarkers for the discrimination between IRI and early graft dysfunction of the pancreas and kidney graft, respectively. Due to the unique characteristic of SPKT, two organs of a very different kind and nature are transplanted simultaneously, of which the pancreas graft is by far the most susceptible for postoperative early graft dysfunction and failure. The kidney graft on the other hand is in comparison much more robust and much less susceptive to ischemia reperfusion injury and postoperative graft failure compared to the delicate pancreas graft. Concerning SPKT and pancreas transplantation alone, only two studies exist which examined this question in detail ,52. GlazApart from the diagnostical pathway for the detection of early graft dysfunction and IRI-associated complications, for instance by the screening and monitoring of serological biomarkers in combination with clinical risk-factor-dependent prediction scoring systems, therapeutical approaches are the key pathways for reducing IRI-associated damages with encouraging early and long-term success following solid organ transplantation . In thisAlthough our current study shows promising results, several limitations are important to discuss.Firstly, the low number of patients in each group and the retrospective, non-randomized design of our current study must be considered, before extrapolating our results to common clinical practice. Therefore, as a future study approach, a detailed multiple logistic regression analysis within a larger cohort should be investigated.Secondly, although this study represents the results of a big German pancreas transplant center with equivalent surgical procedure and compact and robust follow-up data, the long investigation period as well as different anesthesiologic and operative teams and styles may have had an impact on diagnostical and therapeutical decision.Thirdly, although in our analysis a variety of the most commonly used global serologic markers of inflammation  were evaluated, these—except perhaps for pancreatic-specific lipase—cannot distinguish by laboratory chemistry alone between the source of IRI, hence between pancreas- and kidney-specific injury. Therefore, future large prospective multi-center studies are needed to introduce new and reliable sets of graft-specific serological markers , which may identify which organ is affected by IRI and to assess internal/external validity and reliability of the presented data.Early and accurate identification of patients with IRI at risk of developing graft-related complications and especially ePGD as well as eRGD after SPKT is needed to guide clinical decision making and to select patients for novel prophylactic treatment. In our current study, we showed that the combination of peak serum CRP and lipase levels are excellent predictive parameters for the monitoring and detection of early pancreatic graft dysfunction and for predicting IRI-associated pancreas-specific clinical outcome following simultaneous pancreas and kidney transplantation. In contrast, the predictive value of these parameters for early renal graft dysfunction was less specific. The resulting risk groups according to proposed marker cut-off levels allow for improved stratification and better outcome compared to established clinical and paraclinical criteria such as CIT or special donor variables. Therapeutic approaches including different ways of conditioning the graft or recipient for the amelioration of graft-specific IRI aimed to improve prognosis and outcomes in solid organ transplantation. The multifactorial molecular pathophysiology in the setting of IRI in transplantation medicine requires a multimodal approach. Therefore, the most preferable approach is the integration of both pharmacological and technical preconditioning techniques applied to the donor, the donor organ and the organ recipient. Hereby, pharmacological conditioning such as the regulation of miRNAs or complement cascade in combination with machine perfusion seems a promising approach. These novel therapeutical possibilities in combination with strong diagnostical biomarkers and prognostic clinical variables for the prediction of early graft dysfunction may be used in future studies, evaluating new ways to improve impaired microcirculation following pancreas transplantation.


Content-based image retrieval systems (CBIRS) are a new and potentially impactful tool for radiological reporting, but their clinical evaluation is largely missing. This study aimed at assessing the effect of CBIRS on the interpretation of chest CT scans from patients with suspected diffuse parenchymal lung disease (DPLD).A total of 108 retrospectively included chest CT scans with 22 unique, clinically and/or histopathologically verified diagnoses were read by eight radiologists . The radiologists read and provided the suspected diagnosis at a certified radiological workstation to simulate clinical routine. Half of the readings were done without CBIRS and half with the additional support of the CBIRS. The CBIRS retrieved the most likely of 19 lung-specific patterns from a large database of 6542 thin-section CT scans and provided relevant information .p < 0.001) despite the radiologists searching for additional information more frequently when the CBIRS was available . There was a trend towards higher overall diagnostic accuracy  when the CBIRS was available.Reading time decreased by 31.3% .• The decrease in reading time was present despite frequent usage of the content-based image retrieval system.• Additionally, a trend towards higher diagnostic accuracy was observed when using the content-based image retrieval system .The online version contains supplementary material available at 10.1007/s00330-022-08973-3. Content-based image retrieval (CBIR) is an application of machine learning that attempts to alleviate the challenge of searching for digital images in large databases. In comparison to conventional search techniques that analyze text, keywords or other metadata, CBIR analyzes the “content” of the image. In general, CBIR allows the automated search of similar images to a chosen image or part of an image. As an example, this would allow to browse any accessible database for cases similar to the present case based on patterns and other imaging features. Further, this search could be narrowed by adding traditional non-imaging information, as long as this information is available, and the specific CBIR-system was trained on such data. In the radiology domain, it allows radiologists to query an image from a current study and automatically receive similar cases from the local picture archiving and communication system (PACS) or online image databases . In addiThus far, research on CBIR has primarily focused on technical capabilities such as retrieval performance. However, studies evaluating the benefit of CBIR systems in a clinical setting are scarce –7. A preThe study was approved by the institutional review board (protocol number 1288/2018), and the need for informed consent was waived due to the retrospective nature. The study consisted of two phases: baseline and intervention. In the baseline phase, participants read chest CTs without support from the CBIRS but were allowed to use any additional sources they typically use during clinical routine. In the subsequent intervention phase, participants had access to the CBIRS while reading the chest CTs  workstation. For the intervention phase, a shortcut integrated into the PACS opened the CBIRS for the respective case within 5 s. The participants could place a region of interest (ROI) within the selected CT examination. After activating the ROI-drawing mode by pressing the appropriate hotkey, a rectangular ROI of freely adjustable size can be placed within an axial image. The location is fully up to the user, and, in general, will be somewhere in or around a possibly relevant pulmonary CT-pattern. The CBIRS then identified similar cases stored in the PACS, and provided additional information related to the pattern defined by the ROI Fig. .Fig. 2TAll participants were briefed on the CBIRS’ functionality before the intervention phase and had the chance to use the CBIRS on three cases that were not part of the evaluation. Reporting was done based on the image data of the respective cases without access to previous examinations , or non-imaging data . During both phases, participants were allowed to use any source of information . In the intervention phase, the participants had access to the above-described CBIRS.In both phases, every participant read 27 cases, and the time between retrieving the image data and the completion of the reading was measured for each case. Overall, every case was read four times (but never twice by the same radiologist): by one radiology resident and one attending radiologist in the baseline phase, and by a different resident and different attending radiologists in the intervention phase.The reading time was taken by an independent observer. The same observer also noted whether the reader searched for additional information.The database consisted of 108 individual thin-section CT scans — 100 92.6%) with confirmed DPLDs and 8 (7.4%) with inconspicuous pulmonary CT scans. None of the 108 cases was used for training the CBIRS. Chest CT scans performed between 1.1.2018 and 31.12.2018 on one single scanner  were included. Exclusion criteria included the following: (a) acute pulmonary pathologies; (b) patients with any kind of pulmonary surgery; (c) all inconspicuous pulmonary CTs after the first eight cases without any pathological imaging findings. Most of the indications for the 108 CT scans were either a follow-up examination in case of an already known disease or the primary CT-scan in case of a clinically suspected disease. In some cases, the CT findings were incidental, and the scan was conducted for another reason not covered by the exclusion criteria. The final database resulted in 108 cases  where available using prior and follow-up examinations, clinical symptoms, pathology and histology reports, and interdisciplinary board decisions.n = 58), during a pulmonary arterial phase  or during a venous phase .All cases were reconstructed using a sharp (I70f) kernel and 1-mm slice thickness. The acquisition was done with activated automatic tube modulation, 90, 100, or 140 kV and either without contrast agent (A research prototype of contextflow SEARCH Lung CT (contextflow GmbH) was used as the CBIRS. After manually marking a region of interest (ROI), it searches a large database of 6542 anonymized thin-section CT scans  for similar imaging patterns. Each of the CTs in this training dataset included expert labels for 19 lung-specific patterns. A content-specific similarity function based on these expert-labeled data was developed and used to compare image patterns. For any marked region of interest, the CBIRS provides the three most likely disease patterns present. For every pattern class, it additionally provides the cases that most closely resemble the marked ROI in the current scan  marked by the user in the current case. This ROI serves as a query, and retrieval identifies the most similar patches in a large pre-curated database of patches extracted from lung CTs. We created this search database of over 5,000,000,000 such patches, involving two steps: (1) learning a similarity function that puts patches of the same disease pattern in close proximity, so that the nearest neighbors of a newly observed patch have the same disease pattern, and (2) creating an index, so that during actual search the comparison of the ROI with the database patches can be performed rapidly (within 1 s).The similarity function is learned from training data consisting of thin-section CTs. Lungs are segmented and from within the lung region patches are extracted. The entirety of these patches is used to learn an embedding of patches into an embedding space. There, each patch is represented by a coordinate, so that the Euclidean distance between patch representatives can serve as a similarity function. The embedding is performed by a feed forward convolutional neural network, its input is the image patch, and the output the coordinates of the representative in the embedding space.A direct comparison of a query patch with all database patches calculating billions of distances during the interactive use is not feasible. Instead, an index of the coordinates in the embedding space is built to accelerate retrieval to less than 1 s. A separate index is built for each disease pattern class. To this end the embedding is subdivided in a hierarchical fashion to build a two-level data structure, containing information on the coarse and fine location of individual patches in the embedding space.During search, first the ROI is embedded using the feed forward network, the three most likely pattern classes are estimated, and then search for the most similar patches is conducted in the hierarchical index for each pattern class.The 19 lung pattern classes are as follows: airway wall thickening, atelectasis, bronchiectasis, bulla, consolidation, cysts, effusion, emphysema, ground-glass opacities, honeycombing, mass, mosaic attenuation pattern, nodular pattern, nodule, pneumothorax, pulmonary cavity, reticular pattern, tree in bud, non-specific (includes inconspicuous lung regions).p-values equal or below 0.05 are considered statistically significant. A sample size calculation was conducted to establish the necessary number of cases. For the variable “correct diagnosis,” a power of 80%, two-sided alpha of 5% and 20% increase in correct diagnoses were chosen. Under the assumption of 60% diagnostic accuracy for different DPLDs [All statistical computations were performed using SPSS v26.0 . nt DPLDs , this eqp < 0.001), controlling for individual participants, experience level, and whether they looked for information  .Overall diagnostic accuracy was higher in the interventional phase compared to the baseline phase without reaching statistical significance . Of the 154 information searches, 108 (70.1%) were conducted solely with the CBIRS and 46 (29.9%) with the CBIRS plus traditional means.Participants used additional information  more frequently during the intervention phase compared to the baseline phase .Despite searching for additional information more frequently, both the radiology residents and attending radiologists showed a decrease in reading time when the CBIRS was available, and there was a tendency towards a stronger decrease in reading time for senior radiologists . The CBIRS was used in all of these instances . This indicates a more focused and efficient search for information when the CBIRS is available.The main hypothesized advantage of the CBIRS is the streamlined provision of relevant information for the case the radiologist is currently reporting on. One of the most acclaimed informational sources is Radiopaedia, providing over 45,000 cases where quality and actuality are ensured by the editorial board consisting of radiological experts. Several studies have shown Radiopaedia to be the top or one of the most used informational sources , 13. Furp = 0.083).Although participants were given different cases for each phase, reading times may still have been affected by familiarity with the study process and the individual drive to finish the readings. However, even after adjusting for alternative factors in our model, including phase, reader type, and additional information search, the overall 31.3% decrease in reading time remained and was concurrent with a trend towards higher diagnostic accuracy when the CBIRS was available , or non-imaging data . This limits the highest achievable accuracy for complex cases such as in interstitial lung disease. Although the participants may not have had a confident diagnosis available, they still had to commit to giving one, resulting in the shown overall diagnostic accuracy .forcing radiologists to use information search. While previous studies report a benefit mainly for less experienced participants [Previous studies assessing CBIRS in lung imaging have demonstrated significant improvements in diagnostic accuracy: 13% for pulmonary nodules  and 15–6icipants , this sticipants . The CBIAs we encountered delays as a result of the ongoing SARS-CoV-2 pandemic, time between the two phases ranged from 9 and 15 months for individual participants. Thus, increasing experience between phases constitutes another potential bias. However, the results for radiology residents and attending radiologists were similar, even though the latter had a markedly less pronounced relative increase in years of professional experience and finished reports


Oryza sativa L.) cv. Noui Khuea (NK) starch–fatty acid (FA) complexes. The effects of ultrasonically synthesized conditions  on the complexing index (CI) and in vitro digestibility of the starch–FA complex were highlighted. The optimum conditions were 7.5% butyric acid with 20% amplitude for 30 min, as indicated by a high CI and RS contents. The ultrasonically treated starch–butyric complex had the highest RS content of 80.78% with a V-type XRD pattern and an additional FTIR peak at 1709 cm−1. The increase in the water/oil absorption capacity and swelling index were observed in the starch–lipid complex. The pasting viscosity and pasting/melting temperatures were lower than those of native starch, despite the fact that it had a distinct morphological structure with a high proportion of flaky and grooved forms. The complexes were capable of binding bile acid, scavenging the DPPH radical, and stimulating the bifidobacterial proliferation better than native starch, which differed depending on the FA inclusion. Therefore, developing a rice starch–lipid complex can be achieved via ultrasonication.Due to the potential reduction in starch availability, as well as the production of the distinct physico-chemical characteristics of starch in order to improve health benefits, the formation of starch–lipid complexes has attracted significant attention for improving the quantity of resistant starch (RS) content in starchy-based foods. The purpose of this research was to apply ultrasonication to produce intermediate amylose rice ( The desire to improve the quantity of resistant starch (RS) in starchy food components is growing, in order to improve the health benefits . SeveralThe physical modifications  were able to decrease the usage of chemicals and the production of waste, making them deemed secure and safe for the environment. The high-pressure homogenization process, according to Meng , encouraRecently, ultrasonication has also been shown to assist in the integration of lipids into starch molecules , potentiOryza sativa L.) cv. Noui Khuea (NK) flour, an indigenous underutilized intermediate-amylose (22%) short-grain hard rice widely cultivated in Southern Thailand [w/v) for 6 h at 4 °C before being pulverized in a double-disk stone mill. Then, the slurry was placed into a thick fabric bag and squeezed for 10 min using a hydraulic press. The wet-milled flour was then dried at 60 °C in a hot-air oven  to reduce the moisture content to around 13%. The dried sample was ground to a powder, and sieved through a 100-mesh sieve. The rice flour was kept in ethylene-vinyl alcohol copolymer bags at −20 °C until it was needed.The brown rice , then NaOH  was added. The flask was then placed in a water bath at 40 °C for 3 h with a shaker (125 rpm). The pale-yellow emulsion was filtered through a screen with a mesh diameter of 180 μm after incubation. The upper pale-yellow liquid was removed after centrifuging the filtrate for 20 min at 15,600× g . The precipitation layer was centrifuged for 15 min at the same speed after being rinsed twice with distilled water. After discarding the black section of the upper layer, the precipitate was dispersed in distilled water and centrifuged for another 15 min at 15,600× g. To obtain the rice starch, the precipitated layer was moved to an aluminum box and dried at 50 °C for 12 h.To extract the starch, the method of Sun et al.  was usedg for 10 min. The sample was washed thrice with a 50% ethanol/water mixture, and centrifuged at 4000× g for 10 min. The precipitate was dried at 40 °C for 24 h . The starch paste without ultrasonication was used as the control. Then, the optimum ultrasonic time was selected for the second trial on the effect of ultrasonic amplitude (0–40%) on the starch–butyric acid complex. Thereafter, the effect of the butyric acid concentration (1–10%) on the starch–butyric acid complex produced under optimum ultrasonic time and amplitude was studied. Finally, the effect of the FA chain length, including butyric acid (C4:0), lauric acid (C12:0), stearic acid (C18:0), and linoleic acid (C18:2) at the optimum concentration on the complexed formation, was investigated using the optimum ultrasonic time and amplitude. The complexing index (CI) [The first trial was carried out to study the effect of ultrasonic time 0–60 min) on the starch–butyric acid complex at the same amplitude of 20%. The FA (1.5% dissolved in absolute ethanol) (40 mL) was added to the native NK starch dispersion (6 g native starch dispersed in 60 mL distilled water) [0 min on dex (CI)  of all o2 in distilled water). Then, the absorbance was read at 690 nm. The pastes made only of starch were used as a reference. To avoid starch retrogradation, the tests were conducted within 60 min. The CI was calculated as follows:CI represents the percentage of complexation between the starches and lipids . The staThe physico-chemical and in vitro bioactivity of the starch–lipid complexes with varying FA chain lengths were also investigated. The water absorption capacity (WAC), oil absorption capacity (OAC), swelling and solubility indices, and light transmittance (LT) were determined, according to Ashwar et al. .g for 10 min (RC-5B plus centrifuge). The supernatant was carefully poured into an aluminum moisture can before being dried at 105 °C overnight. The sediments were collected and weighed. The WAC and solubility were calculated using the following formulas:For the WAC and solubility index, 1 g of flour was suspended in 10 mL of distilled water and mixed with a vortex mixer for 1 min. The suspensions were heated in a water bath at 30 °C for 30 min with gentle stirring and then centrifuged at 1500× g for 10 min (RC-5B plus centrifuge). Thereafter, the surplus oil was decanted while the residue (weight of oil absorbed) was weighed. The calculation of OAC was as follows:For the OAC, 1 g of flour was mixed with 10 mL of soybean oil for 1 min. After standing at room temperature (30 min), the centrifugation was applied at 1500× g for 20 min (RC-5B plus centrifuge). The swelling index was estimated as the weight of the paste per weight of the dry sample:For the swelling index, 1 g of flour was mixed with distilled water (30 mL). After heating (85 °C/30 min) in a W350 Memmert water bath , the sample was cooled to room temperature and centrifuged at 1500× For LT, an aqueous starch suspension (1%) was generated by heating at 90 °C in a W350 Memmert water bath  for 30 min, while stirring continuously at 75 rpm. The suspension was cooled for 1 h at 30 °C. The samples were kept in a refrigerator for 120 h at 4 °C, and a UV spectrophotometer  was used to measure transmittance every 24 h at 640 nm against a water blank.o), peak temperature (Tp), end temperature (Tend), and enthalpy of gelatinization (ΔH) were recorded. The X-ray diffraction (XRD) patterns of the samples were analyzed by an X-ray diffractometer  [The pasting behaviors were determined by the Rapid Visco Analyser . The pasting temperature, peak viscosity, breakdown, setback, and final viscosity were reported as the pasting parameters. Differential scanning calorimeter (DSC) was used to determine the thermal behavior of the starch samples, using a calorimeter . The onset temperature  . FourierFor the in vitro bioactivities, the bile acid-binding capacity of the starch sample was determined with the colorimetric method described by Ashwar et al. . A 200 m●) scavenging activity of the starch samples was determined, using the method of Li et al. [● solution. After incubation in the dark at room temperature (30 min), the absorbance was measured at 517 nm against blank. A control was prepared using methanol instead of the sample. The DPPH● inhibition was acquired by the following formula:A0 = absorbance of the control and A1 = absorbance of the sample.The 1,1-diphenyl-2-picrylhydrazyl radical  was measured to investigate the prebiotic activity of starch sample [The proliferation rate of the bifidobacteria . SPSS for Windows Version 17.0  was used.A completely randomized design was used for the experimental design and three independent experiments were performed. All of the experiments were tested in triplicate and the data were recorded as mean ± standard deviation (SD). A probability value of p < 0.05), followed by a dramatic decrease in the CI values until 60 min , indicating that ultrasonication enhanced the complexation of starch–butyric acid. An increase in the CI values with increasing ultrasonic amplitude up to 20% was observed, followed by a dramatic decrease in the CI values (p < 0.05). This finding indicated that excessive ultrasonic intensity had a negative effect on the molecular inclusion of FA into the amylose helix. This may result in the degradation of the amylose helical structure, or the final complex structure. The observation was similar to the findings of Liu et al. [The CI values of the ultrasonically treated NK starch, in conjunction with butyric acid by various ultrasonic amplitudes , are shown in u et al. , who revp < 0.05)  d. It was < 0.05) c. It wasThe reduction in the RDS and SDS amounts was found in response to the changes in RS content d, suggesp > 0.05). The highest CI value was noticeable (77.18%) at 7.5% butyric acid and decreased to 73.63% when the concentration of butyric acid was increased to 10% (p < 0.05).p > 0.05; p < 0.05; Increasing the butyric content from 1% to 2.5% had no significant influence on the formation of RS in the ultrasonically treated samples (p < 0.05). However, after the addition of polyunsaturated linoleic acid (C18:2) to the starch molecules, the CI value increased to 65.85%. Overall, the inclusion of the short chain butyric acid (C4:0) resulted in the highest CI value (p < 0.05), whereas the CI values were dramatically reduced when complexing with medium- (C12:0) or long-chain (C18:0) saturated FA into starch molecules, and significantly increased when complexing with the linoleic acid (C18:2) counterpart. The butyric and linoleic acids are naturally liquid FA, whereas the lauric and stearic acids are solid FA. The inclusion of the liquid FA could be more deeply embedded into the amylose molecules than the solid FA. This could be owing to the various FA states’ differing dispersibilities. The solid lipid dispersed poorly in the starch suspension compared to the liquid lipid [The effects of the FA chain lengths on the CI values of the ultrasonically aided NK starch–lipid complexes prepared by 7.5% lipid at 20% amplitude for 30 min are depicted in id lipid , who fouid lipid  found thid lipid  reportedp < 0.05), followed by the starch–linoleic acid complex (69.12%), the starch–lauric acid complex (51.62%), and the starch–stearic acid complex (48.93%) (NK starch–butyric acid complex had the highest RS content of 80.78% ((48.93%) h, respec(48.93%) g. The fl(48.93%) h may be p < 0.05), ranging from 4.27–4.6 g/g depending on the integrated FA. The increased WAC was mostly attributable to the heated gelatinization and intensified ultrasonic treatment, which increased the exposure of the hydroxyl groups in amylose and amylopectin. These data were consistent with the previous study of Ashwar et al. [r et al. , who foup < 0.05), followed by short-chain butyric acid, medium-chain lauric acid, and long-chain stearic acid, respectively. In addition, the swelling index of starch–lipid complexes and native NK starch increased significantly as the temperature rose (p < 0.05), indicating that the swelling index is temperature dependent [The swelling and solubility index of the native NK starch and starch–lipid complexes are shown in ependent .p < 0.05, The solubility index of all of the ultrasonically constructed starch–lipid complexes was slightly increased when compared to the native counterpart (p < 0.05). A higher light transmission was observed in all of the starch–lipid complexes compared to the native starch paste at all of the time points over 120 h (p < 0.05), indicating a lower extent of retrogradation. Thus, the ultrasonically treated starch–lipid complex had less starch retrogradation than the native starch, due to the occurrence of the amylose in the starch–lipid complex. The retrogradation process could not completely take place, because the free amylose molecules were not fully available. This result was in agreement with the study of Ashwar et al. [The impact of cold storage on the LT of the native NK starch and the ultrasonically treated starch–lipid complexes is given in r et al. , who four et al. .p < 0.05), compared to the native starch, which varied depending on the types of FA (846.67 to 3295 cP). The prevalent amylose–lipid interactions may also be related to lower water binding to the amylose molecules, resulting in reduced viscosity for a complex, such as lower peak viscosity. The peak viscosity was significantly reduced (p < 0.05) as the chain length of the integrated saturated FA increased. This finding was in line with Wang et al. [p < 0.05). The order of peak viscosity among the ultrasonically made starch–lipid complexes was highly related to their swelling index , which could be attributed to the steric hindrance power of the C18 chain. Long chain FA, in particular, needs more amylose space to complex, resulting in a less complex formation. According to Wang et al. [p < 0.05), except for the starch–stearic acid complex (90.5 °C). The high melting point of stearic acid may contribute to the higher pasting temperature of its starch complex when compared to other starch–FA complexes. Kaur and Singh [The peak viscosity of the starchy component was impacted by the degree of amylose leaching, the production of complexes, granular swelling, the friction among the swollen granules, and competitive pressure for free water between the leached amylose and ungelatinized granules . The trog et al. , only a nd Singh  reportedo, Tp, Tend, and ΔH, reflecting the change in the thermodynamic properties of the native NK starch and NK starch–lipid complexes, are presented in o of native NK starch, starch–butyric acid, starch–lauric acid, starch–stearic acid, and starch–linoleic acid were 62.51, 96.8, 95.57, 99.82, and 100.48 °C, respectively, indicating that the formation of a starch–lipid complex can raise the first melting temperature. The Tp values for the corresponding samples were 179.54, 125.48, 125.50, 123.04, and 126.28 °C, while the Tend values were 179.54, 125.48, 125.50, 123.04, and 126.28 °C, respectively (p > 0.05), demonstrating the similar ordered formation as influenced by the ultrasonication. The melting temperature of the complexes was found to be slightly lower than that of the native starch (p < 0.05). The endothermic peak of native starch, on the other hand, was largely broad, making it difficult to determine the precise melting point. Furthermore, the increasing ΔH of the starch–lipid complexes was observed, ranging from 528.28–718.54 J/g when compared to native starch (84.96 J/g). Among the starch–lipid samples, ΔH were greater in the following order: linoleic acid > lauric acid > butyric acid > stearic acid, indicating a lower degree of V-type complex formation for the solid long-chain stearic acid. This was highly agreed upon by the CI value , and varied depending on the type of FA. The explanation for this could be related to amylose and FA’s single helical structure, which exposes more hydroxyl groups and contributes to their higher antioxidant activity [p < 0.05), which might be due to the potential radical scavenging activity of the medium-chain lauric acid.The DPPH radical scavenging-activity of native starch and starch–lipid complexes is presented in activity , as inflactivity . Among t600) as an indicator of bifidobacteria growth. The increased OD600 values were observed with increasing concentrations of the native starch and starch–lipid complexes up to 20 g/L (p < 0.05), demonstrating the accelerative potential of bifidobacterial growth. This outcome was very close to Zheng et al. [600 value in all of the treatments, indicating an adverse effect on microbial proliferation. This circumstance could be attributed to high carbon source concentrations in the medium, which resulted in high osmotic pressure and the accumulation of fermentation products, both of which impeded bifidobacterial growth. All of the starch–lipid complexes showed comparable or even higher bifidobacterial growth than the positive control glucose (The starch–lipid complex, having RS as dietary fiber, promotes the growth of bifidobacteria, which resists enzymatic digestion in the small intestine and enters the colon with functions comparable to the non-starch polysaccharide fibers as prebiotic activity. The proliferation of the bifidobacteria in the NK starch–lipid complexes with different FA are shown in  glucose , indicat glucose , in whic glucose h. FurtheUltrasonication promoted the production of starch–lipid complexes with higher CI values and RS contents, as well as superior in vitro bioactivities, that could be used for functional food. The CI and in vitro digestibility of the ultrasonically prepared NK starch–FA complex were varied, depending on the ultrasonic conditions as well as the concentration and type of integrated FA, with 7.5% butyric acid at 20% amplitude for 30 min ultrasonication being the optimum conditions. DSC, FTIR, and XRD measurements revealed that the NK starch–lipid complexes formed V-type complexes. Improved bile acid binding-activity, DPPH radical scavenging capacity, and bifidobacterial proliferation were observed in the NK starch–lipid complex. However, it is necessary to conduct human subject studies to verify the starch–lipid complex’s beneficial qualities. In order to fulfill the practical application on an industrial scale, it is also necessary to investigate the applicability in food products.


In turn, a low starch proportion was hydrolyzed during the simulated digestion , being also slowly hydrolyzed, as deduced from the rapidly digestible starch value . In conclusion, WRB is a suitable matrix for PS enrichment, which allows for obtaining a product with a good nutritional profile and potential health benefits.Bread is one of the staple foods of many countries, and its enrichment with bioactive compounds is trending. This phenomenon is focused on breads with a good nutritional profile, such as wholemeal rye bread (WRB), in which enrichment with plant sterols (PSs) is allowed in accordance with European regulations. The objective of the present study was to optimize the production of a WRB enriched with PS (PS-WRB) and to evaluate the proximate composition and starch digestibility as an indicator of nutritional quality. The rheological analysis showed that the bread dough presents satisfactory farinographic properties  but high water absorption (67%). The PS-WRB is high in dietary fiber and low in protein (20.4 and 7.7%  Noncommunicable diseases are responsible for 71% of deaths worldwide, the majority being cardiovascular, cancer, respiratory diseases and diabetes mellitus . In addiSecale cereale L.) has the highest content of dietary fiber (18.7–22.2%) [Among the different cereals, rye 7–22.2%) , and num7–22.2%) . The Eur7–22.2%) ,7. PS ar–22.2% , y fiber 1.7–22.2% 7–22.2%) ,10. Ther7–22.2%) .For the development of a functional bakery product, it is important to evaluate the rheological properties of the flour to be used, the farinograph analysis being the most widely used for this purpose . Once thRecently, the use of human mastication has been proposed instead of the in vitro oral phase since it more resembles physiological conditions for the digestion of wholemeal rye bread (WRB) . In addiTherefore, the objective of this study is to develop a PS-enriched WRB (PS-WRB) (1.8 g PS/portion) with optimal organoleptic characteristics and nutritional profile, in addition to the functional properties provided by its PS content. To achieve this goal, the farinographic analysis of the bread dough and the optimization of the baking process were carried out. Additionally, the characterization of the proximate composition and evaluation of the in vitro digestibility of the starch in the WRB during the application of the INFOGEST digestion was performed for the first time.w/w) from tall oil , and a blank ingredient without PS containing only the excipients used for the microencapsulation were provided by Lipofoods . L-ascorbic acid  and Celite were purchased from Merck LifeScience S.L.U. . Amyloglucosidase (Aspergillus niger) was obtained from Megazyme Inc. . Absolute ethanol  was obtained from Panreac . Diethyl ether , and potassium hydroxide and petroleum ether (boiling range 40–60 °C) were supplied by Scharlau . Water was purified (resistivity 18.2 MΩ × cm) using a Milli-Q system . For the assays of enzymatic activity and bile salt content and for the simulated gastrointestinal digestion, reagents were prepared according to Makran et al. [Commercial wholemeal rye flour was obtained from HARINERA LA META S.A. . An ingredient source of PS contained microencapsulated free PS  according to the official method from the International Association for Cereal Chemistry (ICC) [The physical properties of the dough were analyzed using a farinograph (Brabenderry (ICC) . The theThe breads were prepared according to the formulation described by Sanz-Penella et al. , with moThe analytical measurements were carried out in triplicate. Analysis was performed with the partially dried milled bread, obtained after drying the bread in an oven at 24 °C overnight and subsequent grinding.1), whereas the second step of drying is at 130 °C during 1.5 h (H2). The total humidity of bread was calculated according to Equation (1):Determining the humidity of the bread products (>13% humidity) was carried out in two stages, according to the official method of the American Association of Cereal Chemists (AACC), with modifications . The firAsh content was measured according to official method . BrieflyThe soluble and insoluble dietary fiber contents were determined by a commercial kit K-TDFR-100A/K , according to the official method . BrieflyLipid content was determined according to the official method of the AACC . BrieflyProtein determination was carried out by the Dumas combustion method, by applying a nitrogen conversion factor (5.83) according to the International Organization for Standardization/Technical Specification .The carbohydrate content was determined by difference according to the following Formula (2):g for 10 min. Finally, 10 µL of supernatant were loaded into a 96-well plate with 290 µL of glucose oxidase-peroxidase (GOPOD) reagent and incubated . In parallel, a blank (10 µL of water + 290 µL of GOPOD) and a D-glucose control (10 µL of 1 mg/mL D-glucose + 290 µL of GOPOD) were prepared. Finally, the absorbance was measured at 510 nm in a multiwell spectrophotometer. The total starch content was not determined in the WRB because the starch digestion was tested on PS-WRB.The total starch content was determined by following the official method , using ag, 10 min). After dilution of the supernatant  with sodium phosphate buffer at pH 6.9, the enzymatic activity was evaluated according to the 3,5-dinitrosalicylic acid assay proposed by the INFOGEST protocol [The enzyme activity and bile salt content used for simulated gastrointestinal digestion was experimentally determined in a previous study , by follprotocol .To analyze starch digestibility, PS-WRB was subjected to simulated gastrointestinal digestion according to the INFOGEST 2.0 method adapted to PS-enriched foods . To apprg, 30 min), 100 µL of supernatant or intestinal digesta was incubated with 400 µL ethanol for 30 min, with agitation by using a sample tube rocker . Then, the sample was centrifuged , and 100 µL of supernatants was incubated with 500 µL of amyloglucosidase solution  at 37 °C for 1 h. Then, 10 µL of sample was loaded into a 96-well plate with 290 µL of GOPOD reagent and incubated for 30 min at 50 °C. Finally, the absorbance was measured at 510 nm. The rate of starch digestion was expressed as the percentage of total starch present in sample hydrolyzed at different times. Starch digestion in the intestinal phase was described using the following nonlinear model: Ct = C0 + C∞ (1 − e−kt), where Ct is the percentage of hydrolyzed starch at time t, C0 is the percentage of starch hydrolyzed in the oro-gastric phase, C∞ is the percentage of hydrolyzed starch in the intestinal phase and k is the constant (min−1). Starch fractions based on their digestibility were determined  in the undigested sample (PS-WRB), oral bolus and intestinal digesta, at different times , by following Azizi et al. , with sot-test (α = 0.05) was used to analyze differences in the proximate composition between PS-WRB and WRB and starch hydrolysis in the oral phase between independent assays. Statgraphics Plus 5.1 software  was used for statistical analysis.A Student The development of a cereal-based functional food contemplates as a first step the analysis of its raw material. The farinographic analysis is useful to evaluate the rheological characteristics of the bread dough , as a prWater absorption is one of the most important characteristics of bread dough and is closely related to the quality of bakery products. In the present study, the wholemeal rye flour exhibited high water absorption, within the observed range for wholemeal rye flours (54.0–66.8%) ,34. The In summary, the data indicated that the farinographic properties of the bread dough obtained with the wholemeal rye flour is suitable and optimal for the development of a functional rye-based bread.Different factors of the breadmaking process significantly affect the features of the bakery products, from kneading to fermentation and baking . Thus, dw/w, dry basis: 58% starch, 12% proteins, 2% lipids, 2% ash and 18% total dietary fiber) [p > 0.05), except in moisture and lipid contents, thanks to PS enrichment.In order to determine the nutritional quality of raw material and breads, the chemical compositions of the flour, WRB and PS-WRB were determined shown in . The proy fiber) . The larBeyond the quantitative value of the nutrients in the flour, it is worth addressing its quality compared with other cereals. This approach will allow us to understand the rest of the results obtained in the study, from the rheological behavior of the dough to the kinetics of starch digestion.w/w, dry basis) [Evaluating the protein content is of interest because it provides information on the nutritional value and is closely related to the rheological properties of the dough. The data obtained show that both wholemeal rye flour and its bread have low protein content . In this sense, rye and wholemeal rye bread showed in previous studies lower protein content than did other breads   . In addiy basis) . On the y basis) , has beey basis) . The higy basis) .w/w, dry basis) [Lipids provide a variety of beneficial properties during bread processing and storage, in addition to driving nutrients and lipophilic bioactive compounds . One stuy basis) . In addiy basis)  stand ouy basis) . Howevery basis)  determiny basis)  and in by basis) . With thw/w, dry basis), with a comparable proportion of the amylose (relative to amylopectin) (27–29%) [w/w, dry basis) in rye flour has been reported [Carbohydrates are the most abundant macronutrients in rye, the majority being starch. Starch content was reported to be lower in rye flour than in wheat (73 vs. 80% (27–29%) . In addireported .A quantitative analysis of carbohydrate, and especially starch content, provides useful information on nutrition. However, beyond the starch content, its digestibility can become a better nutritional indicator because it is related to the glycemic response .Dietary fiber is one of the most characteristic components of rye, responsible for the technological  and funcAs mentioned before, dietary fiber plays a great role in the health properties of rye. It has been suggested that one of the main beneficial effects of rye, the prebiotic action, is related to the content of arabinoxylans . In summThe analysis of the proximate composition allows us to evaluate the nutritional value of a food and its raw materials. This aspect is of interest in a functional food because in addition to the biological effects derived from its content in bioactive compounds, it must present an adequate nutritional profile. Despite all of this, the nutrient content in isolation does not provide complete information on the nutritional quality of a food, because other aspects, such as digestibility, are decisive. In this sense, in cereal-based functional foods, such as PS-WRB, it is of interest to evaluate the hydrolysis kinetics of starch and its different fractions as indicators of nutritional quality. In this regard, starch is classified as RDS, SDS and RS on the basis of its digestibility extent, which depends largely on the structure of the starch and its processing. RDS is rapidly digested and absorbed in the proximal regions of the small intestine, causing a rapid rise in blood glucose. Blood glucose fluctuations can induce stress on glycemic homeostasis systems, with negative health consequences . On the t = 31.114 + 28.8317 (1 − e−0.1064t) (R2 = 0.9881).The results of starch hydrolysis in the different phases of simulated gastrointestinal digestion are presented in w/w). This value is higher than that reported by other authors in subjects of the same age as the volunteer  [Starch digestion begins in the mouth with the action of salivary amylase , an enzy saliva) . It is a saliva) . Numerouw/w) was reached, which indicates that 50% of the weight of the oral bolus corresponded to saliva. In the second, the lower degree of salivation of the subject resulted in an oral bolus with less saliva . The lower presence of saliva was related, as expected, to less starch hydrolysis . These data indicate that the degree of salivation show an intraindividual variability, which has an impact on the oral hydrolysis of starch.Regarding the hydrolysis of starch in the oral phase, two independent assays were carried out, in which a different food–saliva ratio was obtained. In one of them, the recommended ratio of 1:1 : white bread (5.1%), gluten-free white bread (2.4%) , baked b0 = 31.114). This indicates that part of the salivary amylase activity is preserved during the gastric phase. According to the data, salivary amylase acts in the oral phase by hydrolyzing 23% of the starch in just 2 min. When the oral bolus passes into the gastric phase, there is a sudden drop in pH, reducing the activity of salivary amylase, which under these suboptimal conditions acts by hydrolyzing 8% of the starch during the 2 h. Contrary to what was seen in the oral phase, hydrolysis in the gastric phase was lower than that reported in previous studies on white bread (44%), gluten-free bread (23%) [The oral bolus obtained after human mastication was subjected to a simulated gastric phase. The oral bolus with 36% saliva was used since it presents amylase activity closer to that recommended by the INFOGEST method. After the gastric phase, the data reported a 31% ± 5% of digested starch  , baked bad (23%) . One of ad (23%) . The smaad (23%) , which w∞) of the starch was hydrolyzed, a value much lower than that observed for white bread (37.9%) and gluten-free bread (51.1%) [0) and the adjusted equilibrium percentage of hydrolysis during the intestinal step (C∞). The obtained value (59.9%) was again lower than that reported for white bread (87%), gluten-free bread (76.5%) [In the intestinal phase, starch hydrolysis continued until the 30 min stage was reached. During this time, 28.8% (C (51.1%) . This ag (76.5%)  and Fren (76.5%) . Therefo (76.5%)  for Fren (76.5%) . This suThese results agree with in vivo studies showing a lower postprandial insulin response after the intake of rye bread compared with wheat bread ,64, attrMany possible reasons could explain the low digestibility of the starch in the PS-WRB. The first could be related to the structure of bread. Juntunen et al.  reportedIn the development of a cereal-based functional food, it is essential to verify the suitability of the raw materials used. In this sense, the farinographic analysis of the whole rye flour shows acceptable properties, but that could be improved in future studies by incorporating ingredients that provide elasticity to the dough. On the other hand, using a wholemeal flour allows for making the most of its nutritional properties, which in this case are its high fiber content, good fatty acid profile and high protein quality. Moreover, enrichment with PS enhances the functional properties of the final product. Finally, in addition to the optimal nutritional composition of rye bread, a good level of digestibility is observed in starch. In this sense, the low degree of digestibility, which provides a great source of resistant starch, to which numerous beneficial effects for health are attributed, must be highlighted. In this way, the slow release of glucose during digestion could lead to a low postprandial insulin response. In short, WRB is a suitable matrix for enrichment with PS thanks to its properties. However, a tasting study is necessary to evaluate the organoleptic characteristics of the product and assess whether an improvement in the formulation is needed in order to guarantee the acceptability of the bread to consumers. Other aspects remain to be evaluated, such as the effect of PS on starch digestibility. The evaluation of starch hydrolysis in nonenriched bread (to compare it with enriched bread) would provide information on this and on the possible effect of these bioactive compounds on starch digestibility and possibly on the postprandial glycemic and/or insulinemic response.


International Journal of Telerehabilitation (IJT) is a biannual journal dedicated to advancing telerehabilitation by disseminating information about current research and practices. The journal is PubMed indexed, and was recently accepted into Scopus, with indexing to follow.The International Journal of Telerehabilitation (IJT) includes two important clinically based, peer-reviewed articles. Researchers in Singapore describe the use of telerehabilitation to treat frozen shoulder. And, a research team in Australia reports on the delivery of an exercise program designed to improve cardiorespiratory fitness to people dwelling in the community.The current issue of the multi-disciplinary This issue also updates readers on the progress made to establish an inter-state licensure compact for the occupational and physical therapy professions. Progress on these efforts can be tracked online for occupational therapyFinally, this issue contains an announcement for a federally supported regional conference –with no limitations on the geographic location of attendees. The MATRC conference program and audience is notably interprofessional.We cordially invite submissions to the Spring 2020 issue by mid- February 2020. IJT accepts original research, case studies, viewpoints, technology reviews, book reviews, and country reports that detail the status of telerehabilitation.Sincerely,Ellen R. Cohn, PhD, CCC-SLP, ASHA-F, IJT EditorJana Cason, DHSc, OTR/L, FAOTA, Senior Associate Editor


We recently developed a novel Tartary buckwheat variety, ‘Manten-Kirari’, with trace-rutinosidase activity. The use of ‘Manten-Kirari’ enabled us to make rutin-rich food products with low bitterness. This study was intended to evaluate the physicochemical properties and in vitro digestibility of starch isolated from ‘Manten-Kirari’. For comparison, the representative common buckwheat variety ‘Kitawasesoba’ and Tartary buckwheat variety ‘Hokkai T8’ in Japan were also used. The lowest content of amylose was found in ‘Manten-Kirari’ starch (18.1%) while the highest was in ‘Kitawasesoba’ starch (22.6%). ‘Manten-Kirari’ starch exhibited a larger median granule size (11.41 µm) and higher values of peak viscosity (286.8 RVU) and breakdown (115.2 RVU) than the others. The values of onset temperature for gelatinization were 60.5 °C for ‘Kitawasesoba’, 61.3 °C for ‘Manten-Kirari’, and 64.7 °C for ‘Hokkai T8’. ‘Manten-Kirari’ and ‘Hokkai T8’ starches were digested more slowly than ‘Kitawasesoba’ starch. Our results will provide fundamental information concerning the expanded use of ‘Manten-Kirari’ in functional foods. Fagopyrum esculentum Moench) and Tartary buckwheat (Fagopyrum tataricum Gaertn.), are used for food and feed purposes. In Japan, buckwheat food products are mainly buckwheat noodles, which are made from a mixture of buckwheat wheat and flours. Buckwheat has high nutritional values of protein, dietary fiber, phenolic compounds, and minerals in its grains. Rutin, the major phenolic compound of buckwheat, is well known for its health-promoting properties, such as antioxidative [Buckwheat belongs to the Polygonaceae family and is grown as a traditional crop around the world. It has starch-rich grains that are processed, utilized, and consumed like cereals, for example, rice, wheat, and maize. Two popular buckwheat species, common buckwheat  are given in Rapid visco-analyzer (RVA), in which viscosity is monitored over time during a standard heating–cooling cycle under a constant rate of shear, is becoming popular for analyzing the pasting properties of starches. The pasting properties of buckwheat starches assessed by RVA with 8% starch suspension  are presented in Differential scanning calorimetry (DSC), which determines thermal properties, has been used to analyze the gelatinization properties of starches. The gelatinization properties of buckwheat starches monitored by DSC with 30% starch suspension , not with 4%.The amylose content was estimated based on the blue value at 680 nm in accordance with the method previously described . The medIn vitro digestibility of starch was determined by the Megazyme Resistant Starch Assay Kit, 05/2008  in accordance with AOAC method 2002.02 . After dThe determinations of all starch quality parameters were conducted in triplicate. Duncan t-tests were computed to measure variations in the average of all starch quality parameters of each variety.The physicochemical properties and in vitro digestibility of starches isolated from a novel Tartary buckwheat variety, ‘Manten-Kirari’, with trace-rutinosidase activity, as well as the common buckwheat variety, ‘Kitawasesoba’, and a Tartary buckwheat variety, ‘Hokkai T8’, were determined. ‘Manten-Kirari’ starch exhibited the lowest amylose content, largest median granule size, and highest peak viscosity. The hydrolysis rates of ‘Manten-Kirari’ and ‘Hokkai T8’ starches were lower than that of ‘Kitawasesoba’ starch. Some properties, such as lower amylose content and higher peak viscosity, of ‘Manten-Kirari’ starch may be advantageous for making buckwheat noodles with good texture. Moreover, the beneficial health effects of ‘Manten-Kirari’-containing foods derived from the content of starch fraction resistant to amylolytic enzymes as well as the rutin content can be expected.


Dear Editor,Pathologically vascularized corneas are at high risk for immune reactions (IR) and subsequent graft failure after penetrating keratoplasty (PK) . Thus, tPreviously, our group reported that FND combined with subconjunctival bevacizumab treatment prior to PK results in rejection-free graft survival rates of 92.9% after 1 year and 78.4% after 3 years. The mean follow-up time in that study was 560 days [Here, we report 3-year follow-up results of a cohort of 22 vascularized eyes treated with FND in combination with subconjunctival bevacizumab before high-risk PK with a mean follow-up of 1483 days. All patients were followed up for at least 36 months, and IR episodes and graft failures were retrospectively evaluated. An IR was defined by the presence of at least one of the following criteria: new endothelial precipitates or Khodadoust line on the graft, new anterior chamber cells/flare, or new focal/diffuse edema of the graft. Distribution of time-to-event data was described by the Kaplan–Meier method using SPSS Statistics 27 .n = 4), only 1 IR episode (25%)  had a history of a previous graft. Eighteen eyes (81.8%) required additional FND and bevacizumab on the day of PK, whereas four eyes 18.2%) showed complete vessel regression with no need of repeat FND and bevacizumab. The mean time between (last) FND and bevacizumab treatment and high-risk PK was 114.5 days (range 0–794 days). During follow-up, an IR episode was recorded in ten eyes (45.5%) , which may be due to the presence of residual vessels at the day of PK in most of the patients. The 3-year graft survival rate of 72.7% is similar to the rate of the Australian Graft Registry 2015 report, which had demonstrated a survival rate of 70% for corneas with corneal neovascularization [5.5%, whiIn the subgroup of our cohort that did not require simultaneous FND and bevacizumab at time of transplantation because of complete vessel regression, only one IR episode was observed, resulting in a rejection-free 3-year graft survival rate of 75%. This rate seems to be considerably higher than the IR-free survival rate of the eyes requiring simultaneous FND and bevacizumab treatment at the day of PK. Thus, our results implicate that complete vessel regression prior to keratoplasty should be aimed for, although a definitive conclusion cannot be drawn due to the small group size.Further limitations of our study include its retrospective nature, heterogeneity of the time between (last) FND/bevacizumab treatment and PK, and the lack of an internal control group. Nevertheless, to our knowledge, this is the longest follow-up reported in eyes treated with FND and bevacizumab prior to high-risk PK.An attempt to achieve complete vessel regression appears as a viable strategy for rejection-free graft survival. Further research on more potent angioregressive methods such as corneal crosslinking is required to better define the contribution of complete vessel regression to rejection-free corneal allograft survival .


Half of the specimens of each group (n = 7) were subjected to 10000 thermal cycles. The compressive force was applied and the force leading to fracture was measured by using a Universal Testing Machine. The fractured modes were classified under a scanning electron microscope. The data were analyzed through two-way ANOVA, one-way ANOVA, and independent samples t-test (α = 0.05). Among the non-thermocycled subgroups, the monolithic zirconia specimens were significantly more fracture-resistant than the porcelain-veneered zirconia and porcelain-fused-to-metal groups (P<0.05); but it was not the same with aging (P>0.05). Thermocycling decreased the fracture resistance of all groups; however, the difference was not statistically significant (P<0.05). The monolithic zirconia presented higher fracture resistance than the bilayered restorations for screw-cement retained implant-supported restorations. Thermocycling decreased the fracture resistance of all types of restorations insignificantly which can be clinically important.Structural durability of screw-cement-retained implant-supported zirconia-based restorations is an important factor in choosing the best type of restoration for clinical use. This study aimed to evaluate the effects of thermocycling on the fracture resistance of different types of screw-cement-retained implant-supported zirconia-based restoration. Two experimental groups (monolithic zirconia and porcelain-veneered zirconia) and a control group of porcelain-fused-to-metal restorations were fabricated via CAD-CAM ( The durability of screw-cemented implant-supported restorations is critical for the long-term success of these restorations . ImplantZirconium dioxide (zirconia) based restorations have superb biocompatibility and favorable mechanical properties and are widely used in restorative materials, implant abutments, and frameworks for implant-supported restorations , 5. AlthHussein et al.  reportedAlthough the mentioned studies evaluated the effect of different types of restoration on the fracture resistance of both tooth- and implant-supported restorations either with or without thermal aging, no study has evaluated the simultaneous effect of thermal aging and type of restoration on the fracture resistance of screw-cement-retained implant-supported zirconia-based restorations. Consequently, the present study was designed to evaluate the effect of thermocycling on the fracture resistance of screw-cemented implant-supported monolithic zirconia and porcelain veneered zirconia restorations.The null hypotheses were that the three types of restoration would not have different fracture resistance regardless of thermocycling and that thermocycling would not affect the fracture resistance of different screw-cement-retained implant-supported zirconia-based restorations.Fig 1). Forty-two implant-supported crowns were assigned to 3 groups (n = 14 per group) of porcelain-veneered zirconia (PVZ), monolithic zirconia (MZ), and porcelain-fused-to-metal (PFM) serving as the control group.Six implant analogs (5×11.5 mm [diameter×height])  were used to replicate missing maxillary first premolar teeth. The analogs were embedded and fixed in acrylic , and also filled with acrylic up to 1 mm beneath the connection. Six titanium-based abutments  were screwed to the analogs by using a hand-driven wrench  up to 30 N .Fourteen zirconia frames  were manufactured by using computer-aided design/computer-aided manufacturing . Screw access holes 2.7 mm) were created on the occlusal surfaces. The frameworks were then airborne particle-abraded with 50-μm aluminum oxide for 20 seconds at 0.2 MPa, as described by previous studies , 2. Fina.7 mm werFig 2B).To create the metal frameworks by using the CAM machine, wax patterns were fabricated on the titanium-base abutments and were cast with non-precious metal alloy . Feldspathic porcelain  was then fired onto the surface of the metal frameworks to create the same contour as the two other groups .Monolithic zirconia crown patterns were waxed up on titanium abutments by using light-curing resin  with the same specifications as the PVZ group. Wax patterns and abutments were then scanned with the CAD software  and milled with the CAM machine from monolithic zirconia blocks  . The abutment channels and the screw access holes were filled with resin composite  and were left to set completely for 24 hours.Fig 3). The failure modes of the specimens were observed under a scanning electron microscope (SEM)  and classified as the porcelain fracture (fracture within the porcelain), interface fracture (fracture of the interface between the veneer and framework), and framework fracture (fracture within the framework) [Figs 6).Half of the samples of each group (n = 7) were subjected to 10000 thermal cycles (5–55°C with a dwell time of 1 minute at each temperature), which equals one-year use of the restorations in the oral environment according to previous studies , 20. Durα = 0.05 in all tests).The data were analyzed by using SPSS software  The mean values and standard deviations were calculated for each group. Shapiro-Wilk test was used to evaluate the normal distribution, and Levene’s test was used to assess the equality of variances. Two-way ANOVA was used to evaluate the effect of thermocycling and type of restoration and the interaction effect of two factors on the fracture resistance of implant-supported restorations. One-way ANOVA was used to find differences between the restoration groups in each level of thermocycling, and Bonferroni’s post hoc test was used for pairwise comparison of the restoration groups. Independent samples t-test was used to compare the thermocycled and non-thermocycled subgroups in each restoration group . Accordingly, the effect of restoration type (P = 0.005), thermocycling (P = 0.026), and the interaction effect of the two factors (P<0.001) were all statistically significant (Table 2).The mean (±standard deviation) of fracture load according to two levels of thermocycling and MZ, PVZ, and PFM restorations are summarized in P = 0.008). However, this difference was not statistically significant among the thermocycled subgroups (P = 0.274) (Table 1). Bonferroni’s post hoc test showed that the non-thermocycled MZ group was significantly more fracture-resistant (P = 0.008) than the non-thermocycled PVZ group. Independent samples t-test showed that thermocycling insignificantly decreased the fracture resistance in all the three MZ (P = 0.055), PVZ (P = 0.455), and PFM (P = 0.206) restoration groups . The Pareto curve of MZ, PFM, and PVZ in thermocycled and non-thermocycled samples was shown in Fig 8.The result of one-way ANOVA revealed that the non-thermocycled subgroups had significantly different fracture resistances (Table 3).According to the SEM analysis, the failure mode, in the MZ group was full framework fracture along the screw access hole, which was the narrowest part of the restoration in all thermocycled and non-thermocycled specimens (100% framework fracture). In the PVZ group, 57% of specimens both thermocycled and non-thermocycled specimens showed fractures within the veneering porcelain. Moreover, 43% of specimens in the PVZ group showed framework fracture regardless of thermocycling. In the thermocycled PFM subgroup, most of the fractures (71%) were in the veneering porcelain; in non-thermocycling subgroups, 43% of failures were in the interface and 57% were in the veneering porcelain.  with or without thermocycling. This is because the screw access hole weakens the porcelain around the opening and at the cusp tip and disrupts its integrity . This isIn the PVZ group, the fracture was most frequent within the veneering porcelain, followed by the framework; but, never in the interface between the zirconia framework and the veneering porcelain. In the PFM group, fracture occurred both within the veneering porcelain and in the interface between metal coping and the veneering porcelain. This was in line with Mallmann et al.’s study , which rLameira et al.  evaluateJohansson et al.  also obsAll of the investigated types of screw-cement retained implant-supported zirconia-based restorations appear to be resistant to masticatory forces of the premolar region which is about 220–450 N –39.Among the limitations of this in-vitro study was the use of only single crowns instead of multi-unit implant-supported screw-cement retained restorations. Also, only two types of implant-supported zirconia-based restorations were studied in this experiment; further studies are suggested to assess restorations like indirect veneered zirconia crowns.Within the limitations of this study, the following conclusions can be drawn:Without thermocycling, the fracture resistance of the MZ group was significantly higher than the PVZ and PFM groups; while after thermocycling, there was no statistically significant difference between the fracture resistance of different restoration groups.Although thermocycling could decrease the fracture resistance of each restoration type, it was not statistically significant; however, it can be clinically important.All of the fractures (100%) in the MZ group were in the framework along the screw access hole both with and without thermocycling. In the PVZ group, 57% were veneering porcelain fractures and 43% were interface fractures for both thermocycling subgroups. In the PFM group, 57% of failures were the veneering fracture in non-thermocycled specimens and it increased to 71% in thermocycled specimens.S1 Data(XLSX)Click here for additional data file.


Herein, we have fabricated starch–borax double cross-linked network (DC) hydrogels with tough and self-healing properties using a one-pot method. The addition of borax significantly increased the storage modulus and loss modulus of these starch–borax DC hydrogels. The maximum compression stress (~288 kPa) of starch–borax DC hydrogels containing 5% borax was about ten times greater than that of a pure-starch hydrogel. The texture profile analysis values of the DC hydrogels—including hardness, springiness, cohesiveness, and adhesiveness—increased compared to pure-starch hydrogels. In addition, starch–borax DC hydrogels exhibited excellent self-healing and shape-recovery properties. These DC hydrogels, with a variety of excellent properties, have potential applications in agricultural, biomedical, and industrial fields. Hydrogels are three-dimensionally 3D) cross-linked polymeric networks formed by hydrophilic polymer chains ,2,3, andD cross-lAt present, a strategy for preparing chemically and physically double cross-linked network hydrogels has been used to enhance mechanical properties with better self-healing efficiency . Borax, In the current study, we demonstrated a feasible one-pot method for creating starch–borax DC hydrogels with excellent mechanical properties. The DC hydrogel networks were constructed by forming a hydrogen bond between starch chains and a dynamic boron ester bond formed between the starch and the borax. The rheological, mechanical, microstructural, and self-healing properties of the DC hydrogels were systematically analyzed. With excellent mechanical behaviors and self-healing properties, we believe that the application of renewable and biocompatible starch hydrogels could be expanded in the fields of agriculture, food, biomedicine, and tissue engineering.Borax was obtained from Tianjin Guangcheng Chemical reagent Co., Ltd. . Corn starch (amylose content: 28.0%) was obtained from Zhucheng Xingmao Corn Development Co., Ltd. .Starch–borax DC hydrogels were prepared via one-pot method. Corn starch (4.2 g) was added to 23.8 mL distilled water with borax concentrations of 0%, 0.5%, 1.0%, 3%, and 5.0%. Afterward, the mixed slurries were heated for 30 min at 100 °C to ensure complete starch gelatinization. Subsequently, the obtained starch pastes were stored for 6 h at 4 °C to form starch–borax DC hydrogels.A texture analyzer with a P 0.5 probe  was used to characterize the mechanical properties of the hydrogel samples at room condition according to the study of Ge et al. . The comRheological measurements of hydrogels were performed using a DHR-Hybrid Rheometer  using a parallel plate system (PP50). The linear viscoelastic region (LVE) was determined before the shear measurements through a shear strain sweep test (0.01–1000%) at a constant frequency (1 Hz), at 25 °C, according to a previously described method, with some modifications .To ensure the dynamic viscoelasticity, the starch pastes were equilibrated to 50 °C and subjected to frequency sweep experiments, employing angular frequency ranges from 0.1 to 100 rad/s a shear strain of 1.0%. The freshly prepared starch pastes were subsequently cooled to 4 °C for 6 h to obtain starch–borax DC hydrogels. For the same-frequency sweep test of the starch–borax DC hydrogels, the storage modulus (G′), loss modulus (G″), and loss tangent (tanδ = G″/G′) were obtained.The time sweeps of DC hydrogels were performed by cooling the hydrogels to 4 °C at the platform and maintaining that temperature for 120 min, with a frequency of 1 Hz and a shear strain of 1%.The amplitude oscillatory strains were performed according to a study by Huang et al. . The DC For the structural analysis, the starch hydrogels and starch–borax DC hydrogels were frozen at −80 °C, vacuum-lyophilized, and then ground to obtain the freeze-dried hydrogels. The X-ray diffraction (XRD) of the freeze-dried hydrogels was measured with Cu Kα radiation using an XRD diffractometer . An FTIR spectrophotometer  was used to record the spectra of freeze-dried hydrogels. Prior to analysis, the freeze-dried hydrogels were pressed into pellets with potassium bromide. The method was based on previous studies, with minor modifications . The mor3.5% DC hydrogels were broken in half. Then, the cut interfaces were placed together, without any stimulus, at 25 °C. After that, the samples were stretched from both ends to confirm the healing ability. The method was based on previous studies, with minor modifications [The starch–boraxications .The starch–borax DC hydrogels were molded into diverse shapes. Then, the hydrogels were cut into smaller pieces and put into diverse shape molds. They were molded at 25 °C. The self-healing process was observed by taking photographs.p < 0.05 was used.All the experiments were implemented in triplicate. Statistical analysis was conducted with Tukey’s test using SPSS V.17 statistical software . A significance level of The variation in storage modulus (G′), loss modulus (G″), and loss tangent (tan δ) for starch hydrogels with different concentrations of borax at 50 °C (as a function of frequency) are shown in As 0.5%, and starch–borax2%) could not return to their initial values (data not shown). These results confirmed that the network structure of corn starch hydrogels  were destroyed. However, as the strain γ was raised to 500%, the G′ and G″ values of the starch–borax DC hydrogels (starch–borax3.5% and starch–borax5%) also decreased sharply, and the G′ values were higher than the G″ values. After 300 s, when the strain returned to 1%, G′ and G″ quickly returned to their initial values, which suggested the rapid recovery of the internal network and mechanical properties of hydrogels. After three cycles, the starch–borax DC hydrogels (starch–borax3.5% and starch–borax5%) could return to their original state. The results showed that the starch–borax3.5% and starch–borax5% DC hydrogels returned to their starting state in 300 s after 500% shear strain for three cycles, confirming the recovery of the internal network of the starch–borax DC hydrogels. The excellent self-recovery ability of starch–borax DC hydrogels was likely because of the formation of dynamic boron ester bonds. Lu et al. (2017) found that microfibrillated cellulose-poly -borax hydrogels could form reversible covalent cross-links between the hydroxyl groups of poly  or microfibrillated cellulose and borate ions, as well as enhance the elastic response and self-healing ability [The G′ and G″ of the hydrogels, when the alternate step strain was switched from a small strain (γ = 1%) to a large strain (γ = 500%) at a fixed frequency (1 Hz), are presented in  ability .The textural parameters of starch hydrogels and starch–borax DC hydrogels are shown in With the concentration of borax from 0% to 5%, the springiness, cohesiveness, and adhesiveness of starch–borax DC hydrogels increased. In addition, the springiness values in the range of 0.857–0.931 suggest their high elasticity. The cohesiveness of the tested gel increased with the addition of borax, indicating stronger interactions between corn starch and borax. Zhang et al. (2015) demonstrated that tea polysaccharide has the ability to increase the cohesiveness of wheat starch gel via the interaction between tea polysaccharide and wheat starch .The SEM observations of corn starch hydrogels and starch–borax DC hydrogels are presented in XRD patterns of hydrogels are presented in −1 because of the vibration of –OH. A peak at 2926 cm−1 was observed because of the vibration of C–H. The peaks at 1645, 1454, and 1148 cm−1 belonged to O–H bending vibration, C–H bending vibration, and C-O-C stretching vibration, respectively [−1 to 3278 cm−1. The red-shift phenomenon was caused by the consumption of the hydroxyl groups of corn starch chains to form boron ester bonds with borax. Lu et al. (2019) found that the decreased free hydroxyl groups in the borax cross-linked starch nanoparticles could be attributed to the formation of boron ester bonds via the interaction between starch and borax [−1, which was ascribed to the borate ester bonds formed by locust bean gum chains and borax [−1 and 1148 cm−1 decreased, and the band near 1454 cm−1 nearly disappeared. The band shapes and intensities at 849, 759, and 704 cm−1 were changed after cross-linking via borate ions. The results indicated that the OH groups in the corn starch chains could be cross-linked via borax on the starch–borax DC hydrogels. Huang et al. (2019) found that the peak at 833 cm−1 was ascribed to the B−O stretching in B(OH)4−, demonstrating the presence of borax [−1, which was due to the formation of cross-links between hydroxyl groups in poly and borate ions in borax [The FTIR diffractograms of corn starch hydrogels and starch–borax DC hydrogels are presented in ectively . In the nd borax . Thombarnd borax . Lv et aof borax . Spoljar3.5% DC hydrogels was studied, and the results are shown in The self-healing behavior of starch–boraxThe starch–borax DC hydrogels with excellent shape-recovery properties are shown in 5% DC hydrogels may have wide applications in agriculture, biomedicine, materials, and other fields.In this paper, starch–borax DC hydrogels with excellent compression properties and self-recovery capacity were designed and synthesized. The compression strength of starch–borax DC hydrogels containing 5% borax reached 288 kPa at a 94% compression strain, which was increased 10-fold compared to pure-starch hydrogels. Furthermore, the starch–borax DC hydrogels showed remarkable self-healing properties at room temperature. Because of their simple and efficient preparation process, starch–borax