The pre- and post-exercise shear wave speed did not differ. The pre-exercise and post-exercise stiffness for MS (r = 0.613), MG (r = 0.609) and AT (r = 0.583) correlated strongly. The pre-exercise values and changes in stiffness showed a significant correlation (p < 0.001). In professional athletes, acute exercise induces different tissue stiffness changes in AT, MS and MG for each individual. Thus, exercise activity immediately prior to the SWE measurement needs to be factored in when evaluating tissue stiffness.Shear Wave Elastography (SWE) is currently used to detect tissue pathologies, i.e., tendinopathy. For preventive medicine, it is important to examine the sensitivity of SWE and to investigate how stiffness measures are affected by methodological variables. The aim of this study is to examine shear wave elastography (SWE) measures in order to compare the pre- and post-running values and to determine the correlation between the shear wave speed values (m/s). SWE examinations of the Achilles tendon (AT), soleus muscle (MS) and gastrocnemius muscle (MG)) were performed in 24 healthy professional female athletes. Measurements of the shear wave speed (m/s) were taken before and after incremental treadmill running until exhaustion. Correlations were investigated using the Pearson correlation coefficient and were examined for significance using the Student’s  Shear wave elastography is an upcoming technique for multiparametric ultrasound in musculoskeletal tissue. First, the application and the technical aspects of SWE will be outlined. Second, the state-of-the-art of SWE data are presented to understand the possibility of SWE in diagnosing pathologies, e.g., tendinopathies. However, these data are not generalizable because those examinations did not consider professional athletes. Third, the state-of-the-art of SWE examinations in professional sports are given to lead to the aim of the study.As a result of ongoing technical improvements, ultrasound (US) has become more important in functional musculoskeletal (MSK) imaging. Moreover, applications such as shear wave elastography (SWE) or microflow imaging add a quantitative evaluation of muscle or tendon tissue, and have therefore introduced multiparametric US (mpUS) into MSK imaging ,2,3. SWEHowever, SWE needs to be examined further as SWE data taken before and after acute exercise are missing. As tendon stiffness values may vary in relation to exercise activity, it is necessary to examine the acute effect of exercise on the musculoskeletal tissue measured using SWE in professional athletes. This will foster our understanding of tissue stiffness changes in professional athletes, which is needed to be able to develop diagnostic approaches in preventive medicine. As female professional athletes are still under-represented in research , this stUltrasound is the fastest method for assessing tendon and muscle pain. Particularly with the rising availability of point-of-care ultrasound tools, it is a valuable complementary tool alongside the clinical examination for musculoskeletal injuries. In contrast to strain elastography, shear wave elastography showed good intra- and inter-observer reliability in musculoskeletal tissue ,7, is eaSWE has shown good specificity in diagnosing tendinopathy and discriminates between intra-individual pathological tendon changes and contralateral healthy tendons ,11,12. DTendinopathy is a serious condition in professional sports and is highly correlated with a reduction in training, and can also be career ending . SWE canIt is already known that long-term exercise activity in general, and endurance training in particular, affects the shear wave speed (SWS) ,17. FurtAlthough there is data for diagnosing tendinopathy of the Achilles tendon and patellar tendon using SWE, studies examining the influence of an acute exercise—e.g., a training session in professional athletes—are missing. This information is necessary for discovering whether SWE measurements are suitable for determining musculoskeletal tissue stiffness for professional athletes on an active training day.The aim of this study is to evaluate tendon and muscle stiffness before and after a standardized treadmill exercise in professional female athletes to investigate the influence of acute training exposure on Achilles tendon and calf muscle stiffness and SWE measurement. The primary objective is to examine and compare the pre- and post-treadmill running SWS values (m/s) of the Achilles tendon, soleus muscle and gastrocnemius muscle and to determine the correlation. The secondary purpose of this study is to investigate the differences between the Achilles tendon and calf muscle stiffness values (m/s) between professional female handball players and volleyball players. This study focuses on the Achilles tendon and calf muscles as Achilles tendinopathy is a common injury in professional athletes. Chronic tendinopathy leads to a high absence of training and can be career-ending . Calf muThe study included 24 healthy professional female volleyball and handball athletes, who were examined from June until August 2021. Inclusion criteria were: (I) age ≥ 18 years; (II) healthy female professional athletes (>10 h training per week); (III) without any acute (>6 months) musculoskeletal, rheumatic or vascular comorbidities and no previous injuries of Achilles tendon, soleus muscle, gastrocnemius muscle; and (IV) written informed consent to participate in the study. The following exclusion criteria were applied: tendon thickening, tendon neovascularization and hypoechogenity. The study was conducted in accordance with the Declaration of Helsinki and with the approval of the local ethics committee of Charité University Medicine Berlin (EA2/162/19).Baseline patient characteristics were acquired at the time of the first examination. On the day of the measurements and treadmill exercise test, no training was performed before testing. SWE investigation was performed on twenty-four athletes before and after a standardized running exercise, as shown in n = 8]), ligament rupture knee [n = 7]). None reported a tendon rupture. Medication currently being taken were L-Thyroxin (n = 1) and hormonal contraceptives .The median age of the athletes and the median body mass index (BMI) are shown in Thirteen athletes were members of the volleyball national team and eleven of the German handball league. Overall, 84% of all of the athletes trained more than 10 h per week; 16% trained 5–10 h per week.All SWE measurements of the subjects were performed on the same day, applying a standardized protocol. For assessment of the Achilles tendon mid portion stiffness, participants were examined in the prone position with both feet hanging in relaxed position over the examination couch. Leg position was maintained for the measurement of the soleus muscle insertion (MS) and lateral part of the gastrocnemius muscle (MG). Prior to SWE, gray-scale B-mode US was performed in the transverse and longitudinal planes for adequate assessment of the tendon, muscle and probe position. After performing B-mode US to detect the adequate measurement position, this area was marked with a permanent pencil to ensure the same measurement point for the pre- and post-exercise SWE. All examinations were performed using an US system with a 4–10 MHz multifrequency linear array transducer and a center frequency of 7 Mhz . The SWE software  allows for real-time measurement using Acoustic Radiation Force Impulse (ARFI) imaging technology for the quantitative evaluation of shear wave speed.US examinations were performed in the longitudinal plane relaxed positions  to depict-test for the secondary study objective and presented as proportions, both as absolute values and percentages. Correlations were investigated using the Pearson correlation coefficient and examined for significance using Student’s t-test for the primary study objective. A significance level of p < 0.001 was determined and all statistical analysis was performed using both the SPSS software  and Matlab .To determine the normality of the continuous variables, the Kolmogorov-Smirnov test was applied. Variables that were not normally distributed are reported as median and interquartile range (IQR). Categorical variables were analyzed using the Student’s As visualized in p < 0.001 for MS, MG and AT, cf. In the overall cohort, the baseline SWE assessment demonstrated a moderate to strong correlation between the pre-exercise and post-exercise stiffness for the MS (r = 0.613), MG (r = 0.609) and AT (r = 0.583). In both muscles and the tendon, the linear regression shows an increase in stiffness for lower pre-exercise values and decreasing stiffness for higher pre-exercise values . This cop < 0.001 for MS and MG). For both the MS and MG, the respective regression models are given in The linear regression  shows anp < 0.001 for AT). The regression model’s slope and intercept values for the AT are also given in The linear regression  shows anRepresentative images of the change in the tendon stiffness are shown in p > 0.05).There was no difference in the tendon and muscle SWS between the type of sports (volleyball  and handball ; Shear wave elastography is described as an additional ultrasound method for detecting tendon and muscle pathologies and can be a valuable diagnostic tool in prevention and rehabilitation for professional athletes. There is a lack of evidence as to whether SWE is sensitive to tissue changes in the lower limb after a single training session in professional athletes. This is important as examinations of professional athletes are regularly scheduled after training sessions. The aim of this study was therefore to examine the impact of acute exercise on the calf muscles and Achilles tendon, measured through SWE. While the median shear wave speed did not differ between the pre- and post-exercise SWS values, we detected an increase in stiffness for lower pre-exercise values and decreasing stiffness for higher pre-exercise values in the professional female athletes.Exercise activity prior to the measurement can affect the results, as indicated by the increase in stiffness for lower pre-exercise SWS values and the decreasing stiffness for higher pre-exercise values in healthy tendons. This implies an individual response of healthy tendons and muscles to a mean optimal stiffness after a short training session in professional athletes. These individual post-exercise changes should be considered when diagnosing tendon injuries. Transient changes in stiffness after heel drop exercises have been reported; however, only in non-professional participants . DecreasProfessional female athletes seem to have a common AT stiffness after acute exercise between 11 m/s and 12 m/s. Although cut-off values are only useful for one ultrasound system, the general knowledge of changes in tendon stiffness regarding professional athletes is highly important for future research and potential prospective studies. Reference values and stiffness changes shortly after exercise also need to be considered while using SWE in preventive and rehabilitation medicine, as well as the training load .SWE is also an appropriate technique for assessing muscle stiffness  and showFor assessing SWE measurements, it is necessary to adhere to a standardized measurement protocol; joints, tendons and muscles need to be in a relaxed position and transducer positioning should be performed without pressure as the joint position, contraction and pressure do have an impact on SWS . RegardiOverall, several studies have shown that SWE is a suitable diagnostic tool for assessing the stiffness of tendons and muscles, with potential application in rehabilitation and preventive medicine ,36,37. IStandardized SWE measurement protocols with precisely localized transducer positions and exactly defined positions of the test subjects during the measurement would further increase the comparability of SWE data in MSK studies ,40. MoreCycle phases and oral contraception pill intake were not considered. Active muscle contraction was described to be higher during menstruation, while resting muscle stiffness was not influenced by cycle phases . Oral coFurthermore, B-mode power Doppler was not applied in the post-exercise measurements to evaluate a higher or lower blood flow. SWE should be applied in future studies as a multiparametric US for a better understanding of stiffness changes measured by SWE. Pathologies in the musculoskeletal tissue should be assessed through a combination of B-mode power Doppler and SWE. Further studies should also examine male athletes and older athletes and the impact of daily activity before SWE measurements in healthy volunteers. US and SWE should be applied by a highly experienced sonographer in specialized centers, including a focus on musculoskeletal tissue imaging.To summarize, in professional athletes, acute exercise induces individually different tissue stiffness changes in the AT, MS and MG. Thus, exercise activity immediately prior to the SWE measurement needs to be factored in when evaluating tissue stiffness.Shear wave elastography may be applied to point out pathological changes, as changes in the stiffness values correlated with restricted mobility or pain, especially in tendinopathy and muscle inflammation. Regular longitudinal tendon monitoring during the therapy process showed beneficial results for SWE. For professional athletes, easy access diagnostics are necessary to monitor muscle and tendon stiffness to detect the early stages of injuries and to develop preventive therapy algorithms to avoid difficult-to-treat tendon and muscle injuries. Regular longitudinal SWE measurements in combination with a standardized sports medical examination once a year and pre- and post-season SWE measurements may help trainers and doctors to adapt training protocols for the individual athlete to prevent chronic tendon and muscle injuries. This is essential in preventive and rehabilitation medicine for professional athletes and adolescent athletes as lateral imbalances are a risk factor for future injuries and can be detected using SWE . In thisOur study revealed that in professional athletes, acute exercise induces different tissue stiffness changes for each individual, which needs to be considered when applying SWE for diagnostic purposes. While considering these findings in the clinical context, regular screening methods should be complemented by shear wave elastography for sport-specific exposed tendons and muscles as this may help physicians to point out the early signs of injury.


Digital transformation plays an increasingly important role in the growth and competitiveness of small and medium-sized enterprises (SMEs), yet little is known regarding spatial inequalities in their adoption of advanced digital technologies. Using recent data from the Flash Eurobarometer 486, we study the spatial patterns of drivers for the implementation of new digital technologies in SMEs in Europe. In our analysis, the focus is on the possible influence of location. Considerable heterogeneity of SMEs is found in their propensity to adopt advanced digital technologies related to the strength of the local business environment and to the urban/rural hierarchy.The adoption of digital technologies favours the competitiveness, resilience, and internationalisation of firms, but SMEs, which form the backbone of the EU economy, are lagging behind. A recent survey reveals that location greatly influences the probability that European SMEs adopt digital technology. Rural and small-town SMEs are less likely to be adopters, even when country, sector, and firm-specific characteristics are taken into account. However, good business environments always encourage the adoption of digitalisation technologies, whatever the geographic location of an SME. Innovators tend to be adopters, especially when they employ green innovation or management innovation. Larger SMEs, companies that are part of a business group, grow more rapidly, and/or export, are all more likely to adopt digital technologies. Policy-makers need to contemplate the urban/rural-divide and promote strong business environments in all types of locations. Public encouragement towards innovation is likely to indirectly promote easier access to digital technologies. Digitalisation plays an increasingly important role in the growth and competitiveness of firms. Digitalisation is considered one of the main drivers for advanced manufacturing , with a planned budget of 7.5 billion euros, constitutes a further important financial instrument dedicated specifically to supporting the digital transition in the EU. The Digital Innovation Hub Programme of the EU is designed for the promotion of the transition into Industry 4.0 in European regions  across 34 European countries.We use data from the Flash Eurobarometer 486 “SMEs, Start-ups, Scale-ups, and Entrepreneurship” conducted on behalf of the European Commission. This survey was carried out between 19th February and 5th May 2020 in 27 EU countries plus the UK and 6 other non-EU European countries, as well as in 5 non-European countries. The target population involved firms with 1 to 250 employees. The aim of the survey was to collect information on barriers and challenges for European SMEs’ related to growth, sustainability, and digitalisation.Artificial intelligence Cloud computing Robotics Smart devices Big data analytics High-speed infrastructureBlockchainsRegarding digitalisation, firms were asked about the adoption of the following seven digital technologies:In addition, firms were also asked whether they had any interest at all in digitalisation. Our analysis is restricted to the 34 European countries. Table Table The degree of diffusion of DT also varies, however, by sector. The Flash Eurobarometer 486 provides the sector of the firm aggregated at the section level. Based on this information, the mining-water-electricity sector, the manufacturing sector, and the construction sectors can be distinguished. For services, the knowledge-intensive service classification is employed based on the two-digit level. This allows us to identify services that are less knowledge-intensive, services sectors with mixed knowledge intensity, and knowledge-intensive services (KIS) Table . Row 1 oIn Table In a large town or cityIn a small town or villageIn a rural areaIn an industrial areaNear a border with an EU countryNear a border with a non-EU countryRegarding within-country location characteristics, the Flash Eurobarometer 486 asked firms to state in which of the following areas the enterprise is located:The question permitted multiple responses, except for options 1 and 2 which could not be selected simultaneously. Nevertheless, two companies stated that they were in a large town and in a small town; in cleaning the data set, these two observations were dropped. For the remaining firms, six dummy variables were prepared, where a further five companies were dropped for responding that they were located in a large town and in a rural area, and nine companies that responded being located in a small town and in a rural area at the same time. This left us with three exclusive groups of firm location in large towns, small towns, and rural areas. In the sample, 649 companies responded as neither being located in a large town, nor in a small town, nor in a rural area. These companies are classified under being located in other types of locations.The distribution of firms according to the different types of locations is shown in Table Overall strength and performance of the regional business environmentAccess to and collaboration with business partners, such as other enterprises, the public sector, educational institutions, and research organisationsAvailability of staff with the right skills, including managerial skillsInfrastructure for businesses, such as available office space and Internet connectivityThe Flash Eurobarometer 486 also includes a question on how firms rate their regional business environment on a 4-point Likert scale in terms of the following:2 tests are utilised to test for the association between the above characteristics of the environment and whether the firm is a DT adopter. The association is always positive and statistically significant. These results suggest that a good local environment is a driver of digital adoption in SMEs.Table τ is observed.We estimate the probability that a SME has adopted digital innovations. The firm adopts a new digital technology if the anticipated benefits of adoption exceed the cost. However, only the adoption or non-adoption of technology yiτ of firm i of technology τ, τ=1,2 is then captured by a binary choice modelAdoption i’s net value from adopting the new technology τ, is a linear function of observable firm-specific characteristics ci, industry characteristics pi, and location characteristics ri, and where νiτ is a standard normal term.where the latent variable Our key variables of interest refer to the characteristics of the location of a firm. In our estimations, we test for the influence of large town location compared to small town location, rural location, and other locations on the probability that a firm has introduced digital technologies, where the group of “other” locations includes all those firms that have neither responded that they are located in a large town, in a small town, or in a rural location.size, measured in terms of the number of employees (in logs), is included to control for size differences between SMEs. The variable age, calculated as the current year minus the year the company was first registered (in logs), is also included to capture newly created firms. In order to capture the degree of innovativeness of the firm and to distinguish between the different types of innovation, dummies are included for green innovation (green_inno), product innovation (prod_inno), process innovation (proc_inno), management innovation (manag_inno), and for marketing innovation .Our control variables of the model are selected in accordance with the indications taken from previous studies on DT adoption. Based on the literature reviewed in the “Related Literature” section, the variable group which takes value 1 for firms that are part of a national or international group, and zero otherwise.Ownership may also influence the likelihood that a firm adopts digitalisation. Small and medium-sized firms that do not belong to a business group may face financial and technical difficulties when attempting to adopt new technology. In a Hungarian region, foreign multinational enterprises (MNEs) seem more likely than domestic firms to adopt Industry 4.0  decreases by −3.3%. This shows that firms in small towns have a higher probability of not having adopted DT. The smalltown coefficient is also negative and significant for digi_cloud, digi_big, digi_infra, and digi_block. The coefficients of the variables for digi_AI, digi_robot, and digi_smart are also negative but they are not statistically significant.The rural variable is also negative and statistically significant for digi_inno and, specifically, for each type of DT; the exception is digi_smart since in this case the coefficient is negative but not statistically significant. For all specifications, marginal effects are greater than those concerning smalltown. Compared to location in a large town, location in a rural area decreases the probability that a firm has adopted any type of DT by almost −7%. The reduction is still greater regarding digi_infra (−9.2%). On the other hand, compared with smalltown, the breadth of technology adoption in rural areas is clearly more limited.The coefficient of the other location variable are, in most cases, not statistically significant, with two exceptions: they are negative and statistically significant concerning digi_AI and digi_infra. Compared to a location in a large town, location in other areas decreases the probability that a company has adopted digi_AI by −3% and the probability that it has adopted digi_infra by −4.2%.The coefficients of the Column 9 shows the results for the probability that a firm declares that it has no interest in digitalisation. None of the location variables is now significant. This shows that while there are significant differences in the probability of DT adoption across different types of locations, this does not hold for their declared interest, once country, sector, and firm-specific differences are controlled for. Note, however, that declared interest is significantly related to most firm-specific characteristics. Hence, the higher proportion of firms with no interest in digitalisation that is observed for smaller towns and especially for rural areas is principally due the types of firms located in those areas.size variable, which measures the size of the company in terms of their number of employees, is always both positively and statistically significantly related to DT adoption. For DT adoption, in general, a relatively larger size of SMEs increases the probability of DT adoption by 4.3%. In our sample of SMEs, this shows that medium-sized firms tend to be more prone to adopting DT than are smaller firms, and these differences are substantial. Our results do not support those of Vavrecka et al. , our results seem not to support the clear leading role of start-ups in driving digitalisation as suggested in several previous studies  that display a rapid rhythm of growth, those that export, and those that belong to business groups, are also more likely to be adopters than, respectively, independent SMEs, SMEs that display slow growth, and non-exporters. Concerning exporters, our results support those of Giunta and Trivieri  and Terudigi_smart). Involvement in management innovation increases the probability of DT adoption by nearly 8%. Conversely, innovators are less likely to declare that they have not adopted DT or that they are not interested in such technologies. Our results support those of Blichfeldt & Faullant  adoption in small and medium-sized enterprises (SMEs) of the European Union, with a special interest in the possible influence of location. Our article contributes towards the debate on location and technological diffusion with the analysis of a statistically representative sample of firms active in a variety of countries and sectors.Our analysis shows considerable heterogeneity of SMEs in their propensity to adopt advanced digital technologies. Independently of geographic location, the probability of DT adoption is always positively associated to the SME being in a good local business environment, with a pool of possible partnerships, availability of skilled workers, and business infrastructure. Business environments seem to be major drivers of adoption, whatever the location of the SME.Significant differences are also found in the likelihood of the adoption of digital technology of SMEs between large towns, small towns, and rural locations. Firms located in large towns display the most significant depth and breadth of DT adoption even when country, sector, and specific characteristics of firms, such as group membership, are controlled for. In this respect, they are followed by firms located in small towns. In contrast, SMEs located in rural areas are the least likely to be adopters. The probability of adoption clearly decreases the less dense the agglomerations are. These results highlight that the urban-rural digital divide also constitutes a major challenge for the adoption of advanced digital technology by SMEs. However, regarding differences in the interest expressed by firms regarding digitalisation, our results show that such differences are primarily due to specific characteristics of the firm rather than to location in itself.Size, firm growth, pertaining to a group, exporting, and innovativeness are all strongly associated with DT adoption. SMEs do not seem to be substituting DT adoption with innovation; rather, they employ adoption and innovation as complementary strategies. We also find evidence for digital entrepreneurship related to AI, Big data, and blockchains. Our results further suggest the need for a specific analysis of independent SMEs, given the key importance of ownership. This certainly provides an avenue for future research.Our analysis should also be informative for policy-makers that aim to provide incentives to accelerate digital transformation by providing findings of a more nuanced nature that can help in designing tailored policies. This is particularly relevant in the fight against the urban-rural divide, in making growth more inclusive, and in the reduction of spatial inequalities. Our study highlights the importance of focusing on small rural businesses that are active in sectors other than agriculture, a question often neglected by both policy-makers and scholars. The digital weakness of such companies is evident concerning all the spectrum of DT but, especially, regarding high-speed infrastructure. Yet, digital infrastructure provision on its own will remain insufficient. Rural digital hubs could, in addition to infrastructure, provide support to SMEs in the digitalisation process, but their successful implementation is also facing specific constraints (Rundel and Salemink, In fact, our study shows that the European SMEs that are least interested in digitalisation are also those located in rural areas. One possible reason may involve the lack of knowledge regarding digitalisation, particularly about the more advanced applications, and insufficient information on the applied benefits of such technologies. As argued in Yu and Schweisfurth , knowledOur study also reveals the strong association between digitalisation and innovation, “green” innovation being an especially important driver of DT adoption. The presence, in rural areas, of manufacturing SMEs devoted to the processing of agricultural inputs, opens the way to the support of “green” innovation in aspects such as rational use of water, energy saving, and utilisation of agricultural sub-products, which are often wasted. This strategy, in turn, may contribute to the digitalisation of rural SMEs.


A better understanding of these features has the potential to lead to starch-based products with targeted structures and optimized properties for specific applications.Starch is a readily available and abundant source of biological raw materials and is widely used in the food, medical, and textile industries. However, native starch with insufficient functionality limits its utilization in the above applications; therefore, it is modified through various physical, chemical, enzymatic, genetic and multiple modifications. This review summarized the relationship between structural changes and functional properties of starch subjected to different modified methods, including hydrothermal treatment, microwave, pre-gelatinization, ball milling, ultrasonication, radiation, high hydrostatic pressure, supercritical CO Starch is primarily derived from plant carbohydrates and is a renewable biopolymer that is found in various plant tissues ,2, such Starch is a readily available and abundant source of biological raw materials and is widely used in the food, medical, and textile industries. However, as the application prospects of starch continue to improve, the limitations of using natural starch become more prominent. For instance, natural starch is insoluble in sluoat room temperature, is prone to retrogradation, and is susceptible to viscosity loss under low pH and high-temperature conditions. These properties significantly hinder the application prospects of starch . ResearcPhysical modification technology is an economical and eco-friendly technology that can be used to modify starch properties. Physical modifications can usually be divided into thermal and non-thermal treatments . Heat trHydrothermal treatment is a physical modification method that preserves the surface characteristics of starch granules and that maintains the starch structure better than other physical modification methods. The common methods include annealing (ANN), heat moisture treatment (HMT), and superheated steam (SS). ANN and HMT are executed above the glass transition temperature and below the gelation temperature of starch ,13. The The results reported by Ma et al. agreed well with the results reported by Dutta et al., Shi et al. and Xiang et al. ,20,22,23Microwave treatment involves the use of electromagnetic radiation at frequencies between 300 MHz and 300 GHz . These rPregelatinized starch has a special structure, such as hydrogen bond breaking porosity, where the crystal zone in the pregelatinized starch particles is completely or partially destroyed and has properties such as cold-water solubility and high viscosity compared to natural starch. It can reduce the processing time and heat loss in later applications, thus shortening and simplifying the process. For instance, pregelatinization is used for thickeners in many instant food products. These kinds of products require only the addition of hot water with stirring before serving, such as baby food, instant soups and instant deserts. Pregelatinized starch is a kind of starch modified by physical modification. It can significantly change the viscosity, water-binding ability, gel structure, and other properties of starch. Adding pregelatinized starch to natural starch, or the direct replacement of natural starch with pregelatinized starch, can shorten and simplify the production process while improving the quality of the final product . The conSpray drying is a method of modified starch that combines several drying steps into one, resulting in reduced drying time. This method can be efficiently used to realize the mass production of samples. Tay et al. introduced a low-temperature spray-drying process that yielded glutinous rice starch in high yields . The proDrum drying involves two stages (pasting and drying) and can be accomplished using single-drum or double-drum dryers . This meStarch extrusion technology is a thermo-mechanical process that breaks the bonds in starch, resulting in the pasting, melting, and degradation of starch. This technology involves the execution of several unit operational steps, such as mixing, cooking, kneading, shearing, shaping, and forming . ExtrusiGandhi et al. investigated the effect of twin-screw extrusion on the properties and quality attributes of corn and potato starch . The watThe results differ depending on the raw material used, extrusion parameters, and extrusion conditions. Qi et al. studied the extrusion process of pea starch (moisture content: 25–55%) using a twin-screw extruder (aspect ratio: 26) . The lowImproved extrusion cooking technology (IECT) improves the performance of the extrudate. A low amount of energy is consumed during the process, and IECT is a promising and improved method that can be used to treat and process starch. Cheng et al. followed the IECT process for the extrusion of buckwheat flour, and the results revealed that the IECT-treated buckwheat flour samples retained favorable functional components and physical properties . HoweverIn conclusion, the parameters of the pregelatinization method are universal, and pregelatinized starch has excellent pasting properties, which can be used in a wide range of applications. Each pregelatinization treatment has advantages and disadvantages, therefore, it is necessary to further optimize the pregelatinization method to meet the needs of different food industries.Ultrasonic modification is a processing technique that results in the physical depolymerization of starch. Ultrasound helps to improve the physicochemical properties of starch. The advantages of the process lie in the use of small amounts of chemicals and the consumption of less amount of time . SatmalaRadiation technology can be potentially used to improve the solubility and enzymatic digestibility of starch, and thus, it can be widely used in the food industry . RadiatiBall milling modification involves the exploitation of friction, impact, shear, or other mechanical forces to modify the structure and properties of starch granules  56]. Ba. Ba56]. The HHP-based treatment method is a new, non-thermal, and environmentally friendly treatment technique that is easy to control . This me2, as a solvent in supercritical fluids, has an easy-to-control critical value, is convenient to use, and is characterized by a much lower critical temperature than other commonly used solvents. This fluid exhibits both gas and liquid properties, such as low viscosity, high diffusion coefficient, and good dissolution properties [2. They also studied the solubility and volume expansion properties of the starch samples in supercritical CO2. Analysis of the SEM images revealed that the average diameter of the treated starch granules was higher than the average diameter of untreated starch granules when the samples were treated with supercritical CO2. This resulted in swelling of the starch granules. This may be due to the absorption of CO2 by starch. However, the extent of swelling realized in this case was negligible compared to the extent of swelling realized following other modification methods. The authors pointed out that the introduction of different functional groups exerted varying degrees of effects on the physicochemical properties of modified starch. Moreover, the supercritical fluid-modification approach can be combined with physical, chemical, and biological methods to obtain starch samples with the target properties. 2 unit. A supercritical fluid is a compound that is formed above critical pressure and temperature and is a green solvent that is inexpensive, safe, non-toxic, and environmentally friendly . CO2, asoperties . Villegaoperties . The resChemical modification involves the introduction of new functional groups into the polymer molecules. This results in significant changes in the physicochemical properties of starch molecules ,74. StarThe oxidation of modified starch results in the conversion of hydroxyl groups to carbonyl and carboxyl groups, resulting in the depolymerization of amylose and amylopectin . The cheTung et al. studied the oxidation of starch extracted from pineapple honey seed . They usThe electrolysis technique can potentially address most of the problems associated with chemical modification. Food-grade chemicals are used in small amounts during electrolysis. Thus, these can be easily removed from the final products. Castanha et al. used tapioca starch as the raw material . They oxOzone is a robust and environmentally friendly oxidant. It is a stronger oxidizing agent than sodium hypochlorite and hydrogen peroxide . Ozone cOzone treatment is an efficient and widely used technology. A correlation analysis was conducted by Castanha et al. for the ozone treatment of cassava, corn, and potato starch samples . The ozoEtherification is a modified method that, by introducing the lipophilic functional groups, is used to improve the water resistance of starch . The mecWang et al. used 3–9% propylene oxide to hydroxypropylate normal wheat starch, glutinous wheat starch , and gluEsterification reactions can be conducted to effectively modify the structure of starch granules to improve the application prospects of starch. The skeletal structure of starch bears a large number of hydroxyl groups. Hence, starch can be esterified with acids and their derivatives . Starch w/v) hydrochloric acid [A concentrated slurry is treated with acid at a temperature below the starch pasting temperature during acid hydrolysis. The method is also referred to as acid dilution . Usuallyric acid . The modAbdorreza et al. studied the effect of acid hydrolysis on the physicochemical and rheological properties of sago starch . It was Acid hydrolysis can impart specific properties to starch if the pH, hydrolysis time, and molecular weight of starches are controlled . AlthougEnzyme modification technology can be used to effectively control the specific properties of starch. The use of biological modification methods helps to reduce the yields of byproducts. High specificity for hydrolysis products and high yields of target products can be achieved using these techniques ,119. TabGenetic modification of starch not only helps in understanding the mechanisms associated with the biosynthesis of starch but also presents a platform to expand the application prospects of starch. Biogenetic mutations impart starch with unique physicochemical properties. Wang et al. performed targeted mutagenesis with IbGBSSI and IbSBEII (genes associated with biosynthetic pathways in sweet potatoes) using CRISPR/Cas9 technology and found that amylose content in modified starch was higher than that in natural sweet potatoes . Luo et The dual modification method is widely used for starch modification, as it can address the shortcomings of the single modification method. The dual modification method is developed using a combination of two modification methods. It can be broadly classified into six categories: physical–physical modifications, physical–chemical modifications, physical–biological modifications, chemical–chemical modifications, chemical–biological modifications, and biological modifications. There is a significant correlation between the physicochemical properties of dual-modified starch samples . The duaDual physical modification was more effective than single physical modification. Zhou et al. compared the physicochemical properties of corn starch and potato starch modified by ultrasonic and microwave alone and by dual treatment . The resThe combined physical and chemical modification facilitates the further acquisition of starch with target properties. Li et al. compared the granular, physicochemical, and thermal properties of single-modified and corresponding freeze–thaw-assisted acid hydrolysis starches . The stuPhysical modification methods are currently the preferred method for starch modification due to their green, efficient, and easy-to-operate nature, while enzymatic hydrolysis is used as a green modification method. Davoudi et al. investigated the effect of low-temperature plasma treatment and enzymatic hydrolysis on the physicochemical properties and microstructure of porous corn starch, and SEM images showed that deeper grooves appeared on the surface of the combined starch, and the combined starch showed the highest solubility, swelling capacity, and total pore volume . Lin et Dual-chemical modification makes full use of the advantages of single-chemical modification, and therefore, its modification effect is more obvious. Javadian et al. investigated the effect of dual-chemical modifications on the functional, microstructural, and thermal properties of cassava starch by acid hydrolysis and then by hydroxypropylation of cassava starch . The resThe inherent advantages of the biomodification approach are: “green” and efficient. Dual biomodification further consolidates this advantage and effectively enhances that of single biomodification. Jeong et al. investigated the effect of α-amylase in combination with α-amylase and cellulase on the physicochemical properties of oat flakes and starch and showed that enzyme modification resulted in a significant increase in starch solubility and swelling and that the combined enzymes caused more intense depolymerization of starch molecules than single enzymes . Guo et Studies have shown that modified starch presents better physicochemical properties than native starch, and starch modification significantly expands the market for starch byproducts. Currently, people are placing great emphasis on eating well and healthily. With the rise in the concept of homology of medicine and food, the starch industry has been further boosted. For instance, Pueraria lobata starch high in isoflavones can be used as food and in the medicinal industry. As a result, it is a healthy and nutritious choice. Pueraria lobata starch is an underexplored native starch, and it will have great application in functional food ingredients if it is modified. Additionally, as the global population continues to grow, the development of modified starch with improved functionality and sustainability will become increasingly important to meet the demand for food and other industrial applications. Research on modified starch is expected to focus on developing more efficient and eco-friendly modification methods as well as on exploring novel starch sources and their potential uses in the future.


The effects of ascorbic acid treatment alone and in combination with degreasing or hydrothermal treatment on eating quality and in vitro digestibility of brown rice were explored for improving poor mouthfeel and low digestibility, and the improvement mechanism was investigated. The results indicated that the texture of cooked brown rice was significantly improved by degreasing combined with ascorbic acid hydrothermal treatment; the hardness and chewiness decreased to the level of polished rice; the stickiness increased three times of the cooked untreated brown rice; and the sensory score and in vitro digestibility were significantly enhanced from 68.20 and 61.37% to 83.70 and 79.53%, respectively. In addition, the relative crystallinity and water contact angle of treated brown rice were respectively reduced from 32.74% and 113.39° to 22.55% and 64.93°, and normal temperature water uptake significantly increased. Scanning electron microscope showed that the separation of starch granules occurred inside cooked brown rice grain obviously. The improvement of eating quality and in vitro digestibility of brown rice is conducive to enhancing the consumers acceptance and human health. Almost half of the world’s population lives primarily on rice. It is frequently consumed in the form of milled rice by removing the bran layer from brown rice, which is also referred as polished rice . The braSeveral methods have been reported to decrease the cooking time of brown rice and enhance the mouthfeel and digestibility of cooked brown rice, such as partial milling, freeze-thaw treatment, pregelatinization, germination, enzymatic hydrolysis, and ultrasonic treatment ,4,5,6,7.The lipid content of brown rice is about 1.6~2.8%, which is higher than polished rice, mainly distributed in the rice bran layer . The ranAscorbic acid is a small molecule that can easily penetrate into the gap between starch granules and is a cheap and safe food-grade additive . AscorbiThe objective of this work was to investigate the effects of ascorbic acid treatment alone or in combination with degreasing and/or hydrothermal treatment on eating quality and in vitro digestibility of cooked brown rice, and provides an effective way to prepare the prefabricated brown rice for sale in the market and easier cooking by consumers. The changes in cooking quality, relative crystallinity, water droplet contact angle, normal temperature water uptake of treated brown rice, and microscopic morphologies inside the cooked treated brown rice were investigated to reveal the underlying reasons for the improvements of texture, sensory, and in vitro digestibility.−1 solid) were purchased from Sigma-Aldrich Ltd. . Amyloglucosidase (3260 U/mL), the total starch assay kit and the glucose assay kit were all obtained from Megazyme International Ireland Ltd. .Non-waxy japonica brown rice (BR) and polished rice (PR), “Nanjing 9108” cultivars, Oryza sativa L., were harvested in Xuyu County, Jiangsu Province, China, whose moisture content was 13.56 ± 0.72% and 13.12 ± 0.48% respectively. Ascorbic acid (≥99.0%) and absolute ethanol (≥99.5%) were purchased from Sino Pharm Chemical Reagent Co., Ltd. . Pepsin (250 U/mg protein), α-Amylase (250 U/g solid), pancreatin (8 × USP), and invertase (300 U·mgBrown rice was degreased according to the reference method  to obtaiRice sample of 8.0 g was washed twice and soaked in distilled water (7.2 mL) for 1 h in an aluminum cup covered with tinfoil and then cooked as described by Ohno et al. . After sSensory evaluation was carried out by the method with minor modifications ,25,26. ISimulated in vitro salivary-gastrointestinal digestion of cooked rice was performed using a reference method with minor modifications . Weigh 2∞ is the estimated percentage of final starch digestion, Ct is the starch digestibility at t min, and k is the starch digestion rate coefficient. Then the area under the curve was calculated.A standard curve for starch digestion at different glucose concentrations was constructed, which followed Equation (1) .Ct = C∞Equation (2) was provided to calculate the glycemic index (GI) .GI = 39The glass plate-white nucleus method was used for the measurement of optimal cooking time (OCT) described by Mohapatra et al. . HeatingThe X-ray diffractometer  was used to characterize the crystalline structure of the starch in treated brown rice. The scanning rate was 5.0°/min and the scanning range (2θ) was 5–40° . MoreoveThe hydrophilicity of brown rice grain was characterized by water droplet contact angle with a contact angle meter . A droplet of distilled water (1.5 μL) was dropped on the surface of rice grain and then the contact angle was obtained by sessile drop method . Analysi1 is the NTWU, %; Mi is the mass of brown rice after soaking, g; M0 is the mass of brown rice before soaking, g.Normal temperature water uptake (NTWU) of rice grains was obtained by measuring weight difference before and after soaking . Rice grThe freeze-dried cooked rice grains were ground and then passed by a 105 μm sieve screen to obtain appropriate particles in size for observation. The scanning electron microscope  was used to scan and take photographs of the sample at an accelerating voltage of 5 kV.p < 0.05). All statistical analyses and graphs were performed by using SPSS Software (Version 19.0.) and Origin 2022 software, respectively.All data were determined in triplicate, unless otherwise indicated, and the results were expressed as mean ± standard deviation. The data were further processed through analysis of variance (ANOVA) by Duncan’s multiple range tests , ascorbic acid hydrothermal treatment (BR-AH) further improved the sensory scores  of cooked brown rice. Furthermore, degreasing combined with ascorbic acid hydrothermal treatment (BR-DAH) markedly improved the sensory scores  of cooked brown rice, and there was no obvious difference between the sensory score items of treated brown rice (BR-DAH) and polished rice (PR) except for odor, although the total sensory score of treated brown rice was still significantly below than polished rice. Hydrothermal treatment can soften the bran layer and promote the volatilization of bran odor of brown rice . Thus, cStarch is the main component of brown rice, which is hydrolyzed into glucose in the human body to provide energy, and its digestibility is crucial to human health . For con∞) calculated from the first-order kinetic reaction is listed in ∞) increased significantly in the order of ascorbic acid treatment alone, degreasing combined with ascorbic acid treatment, ascorbic acid hydrothermal treatment, and degreasing combined with ascorbic acid hydrothermal treatment. Furthermore, the starch digestibility of cooked brown rice could be enhanced from 61.37% of cooked untreated brown rice to 79.53% after degreasing combined with ascorbic acid hydrothermal treatment. This, to a large extent, overcomes the low digestion rate of brown rice. The in vitro digestibility improvement of brown rice by degreasing combined with ascorbic acid hydrothermal treatment is likely to be achieved through increasing contact area with digestive enzymes and through promoting the full swelling and gelatinization of starch [The starch digestibility at the end of the reaction (Cf starch .∞), which significantly increased in the order listed in In addition, it can be seen that the starch digestion rate coefficient (k), glycemic index (GI), and hydrolysis index (HI) of brown rice for each treatment were markedly overtopped than those of untreated brown rice , and theThe effects of ascorbic acid treatments on cooking quality of brown rice are shown in The heating water uptake (HWU), volume expansion rate (VER), and solid loss (SL) were significantly improved by ascorbic acid treatment alone and in combination with degreasing and/or hydrothermal treatment , and theThe effects of ascorbic acid treatments on relative crystallinity of the treated brown rice are shown in The bran layer of brown rice is a hydrophobic material including lipids, proteins, fibers, and ashes . The effTo further reveal the reason why ascorbic acid improved the eating quality of brown rice, normal temperature water uptake (NTWU) was determined, as presented in 1,F2), indicating an obvious separation of starch granules [1,A2), which may be due to separation difficulty of starch granules resulting from the low degree of gelatinization. After ascorbic acid treatment alone, some pits appeared inside the cooked brown rice, but the opening degree of the pits was small, indicating that ascorbic acid promoted the gelatinization  of brown rice to some extent. After degreasing combined with ascorbic acid treatment, there were many tiny holes and a few larger pits inside cooked brown rice , both of them were shallow, but the degree of gelatinization appeared to be higher than ascorbic acid treatment alone. After ascorbic acid hydrothermal treatment, the tiny holes inside the cooked brown rice became dense, showing a looser honeycomb structure in the local areas, and more macropores appeared , indicating that ascorbic acid hydrothermal treatment can effectively promote the gelatinization of starch. After degreasing combined with ascorbic acid hydrothermal treatment, there were more starch granule abscission pits inside the cooked brown rice, with a larger opening degree, indicating that starch granules were obviously separated, which is very similar to polished rice . Therefore, degreasing combined with ascorbic acid hydrothermal treatment markedly promoted the separation of starch granules inside cooked brown rice, and improved the uniformity of starch gelatinization, which was consistent with the increases of solids loss and stickiness of the treated cooked brown rice.The effects of ascorbic acid treatments on microscopic morphologies inside cooked brown rice are shown in granules ,23. Convnization B1,B2 of own rice C1,C2, boappeared D1,D2, inhed rice E1,E2. ThIn the gelatinization process of the treated brown rice, water is easier to penetrate into the rice grains through the surface layer, which makes the internal starch granules swell adequately and separate each other, therefore improving the degree of starch gelatinization and eating quality of the treated brown rice. The separated starch granules may break more easily, and the small starch molecules can easily migrate outside the rice grain, which helps to improve the stickiness and digestibility of cooked rice. Therefore, the cooked brown rice after degreasing combined with ascorbic acid hydrothermal treatment has higher stickiness, better mouthfeel, and easier digestion. The increase in amorphous structure inside rice grain and more fissures and tiny holes on the surface are consistent with the increase in HWU and SL, showing that the gelatinization degree of brown rice depends on the internal and external permeability of the rice grain.For the internal structure of brown rice grains, degreasing combined with ascorbic acid hydrothermal treatment decreased the relative crystallinity of brown rice and thus increased the amorphous structure, which was helpful for water uptake and gelatinization of starch in brown rice. For the surface of brown rice grains, the degreasing combined with ascorbic acid hydrothermal treatment markedly decreased the water droplet contact angle and thus enhanced the surface hydrophilicity. These changes were confirmed by the significant increase in NTWU. Therefore, the increase in internal amorphous structure and surface hydrophilicity enhance the water uptake capacity of brown rice grains in a limited time during cooking, significantly improve the cooking quality, and thus improving the texture, sensory score, and in vitro digestibility of cooked brown rice. The coordination role between interior  and surface (contact angle) of rice grain is the underlying reason for the improvement of brown rice eating quality. As for microscopic morphologies of brown rice, degreasing combined with ascorbic acid hydrothermal treatment can contribute to promoting the separation of starch granules inside cooked brown rice grains. The above results show that degreasing combined with ascorbic acid hydrothermal treatment can effectively improve the eating quality and digestibility of brown rice, which is helpful to enhance the acceptability of the prefabricated brown rice after treatment as a staple food consumed.


P = 0.004). There were no substantial differences in donor-, recipient- and transplant-related characteristics in LTs performed on weekdays or holidays. On Monday, fewer transplants were performed . At multivariable Cox regression analysis, LTs performed during the holiday or during the different days of the week were not found to be independent risk factors for the risk of 3- and 12-month graft loss. At three-month survival curves, no differences were observed among the transplants performed during the holidays versus the workdays . The range of graft survival rates based on the day of the week was 81.6–86.9%, without showing any significant differences (P = 0.57). Fewer transplants are performed on holidays and Mondays. Survivals are not affected by holidays or the day the transplant is performed.Poor data exist on the influence of holidays and weekdays on the number and the results of liver transplantation (LT) in Italy. The study’s main objective is to investigate the impact of holidays and the different days of the week on the LT number and early graft survival rates in a multi-centric Italian series. We performed a retrospective analysis on 1,026 adult patients undergoing first deceased-donor transplantation between January 2004 and December 2018 in the three university centers in Rome. During the 4,504 workdays, 881 LTs were performed . On the opposite, 145 LTs were done during the 975 holidays . Fewer LTs were performed on holidays ( Liver transplantation (LT) represents the best curative treatment for end-stage liver disease and unresectable hepatocellular carcinoma (HCC), with 5-year survival rates ranging 70–80% , 2. UnfoTransplant surgery is a non-elective surgical procedure with unpredictable surgical timing determined by the availability of donor organs and the need to optimize the graft cold ischemic time (CIT) , 8. ConsStudies focused on other types of emergency surgery reported higher mortality rates in patients admitted during the night or on the weekends, mainly due to limited human resources, sleep deprivation, and surgery delaying for time-sensitive interventions –13.In transplant surgery, postponing the donation procedure to start during regular working hours relates to several potential drawbacks, like the inappropriate use of the intensive care unit (ICU) beds, the risk of losing the donor due to hemodynamic instability, and the interference with elective scheduled surgery in the donor and recipient hospitals , 8, 14.Some studies have already investigated the effect of night shifts and weekends on LT results –19, showThe study aims to investigate the effect of holidays and weekends on the transplantation activity in three university transplant centers in Rome to establish if an “outside working hours” effect should be reported in terms of the number of LT performed and post-LT outcomes.We performed a retrospective analysis of the data from 1,026 adult (≥ 18 years) patients undergoing a first DDLT between January 1, 2004, and December 31, 2018, in the three University Centers of Rome .The day of LT operation starting was coded as the day of the operation. We defined Holidays Transplantation (HT) as any LT operation that occurred: (a) between 20:00 h on a Saturday and 08:00 h on a Monday; and (b) during one of the thirteen different Italian public holidays. Work days transplantation (WDT) was defined as any transplant performed during regular working days (from Monday morning to Saturday evening).U test and Fisher’s exact test compared continuous and categorical variables, respectively.Continuous variables were reported as medians and inter-quartile ranges (IQR). Categorical variables were reported as numbers and percentages. The Mann–Whitney A multivariable Cox regression analysis was constructed to identify the risk factors for 3 and 12-month graft loss. Hazard ratios (HR) and 95.0% confidence intervals (95% CI) were reported.P < 0.05 were considered statistically significant. We used the SPSS statistical package version 24.0 .Survival probabilities were estimated using the Kaplan–Meier method. Survival rates comparisons were estimated using the log-rank method. Variables with a P = 0.004).The donor-, recipient-, and LT procedure-related characteristics are reported in Table P = 0.2), MELD score , HCC , and underlying liver disease.As for the recipient characteristics, no statistically relevant differences were observed between the two groups. In detail, the recipients transplanted during the workdays presented similar age , age , causes of death, comorbidities, smoking or alcohol abuse history, hemodynamic instability , and blood tests of liver function respect to the HT group. The only statistically relevant difference was a higher number of biopsies performed during the workdays .As for the donors, several similarities were observed between the two groups. In detail, the WDT group presented a similar sharing . Also, the BAR score was statistically significant (P = 0.008). Other donor-specific scores like the DRI, the Eurotransplant-DRI, and the D-MELD were not statistically relevant.As for the transplant procedure, CIT was shorter during the holidays . As for the early survival rates after LT, 3-month patient death rates were similar between WDT and HT groups . Similar results were observed in terms of 3-month graft loss  and need for early re-transplantations .After LT, reoperation rates were similar in the two groups    Fig. .Table 2NP = 0.57  and CIT  were independent risk factors for 3-month graft loss. Neither LT performed during the holiday  nor the LT performed during the different days of the week were statistically relevant variables  was an independent risk factor for 12-month graft loss. Neither LT performed during the holiday  nor the LT performed during the different days of the week were statistically relevant variables  an impaired technical performance or perioperative decision making due to fatigue, (b) several previous surgeries performed by the transplant team on call for the weekend, (c) and the surgical services support staff heterogeneously composed by members of cross-disciplinary teams also involved in other surgical emergencies.The adverse effects of fatigue on technical and cognitive skills are well-documented for surgeons and anaesthesiologists , 10. NevInterestingly, the results of our series are in line with these results, with similar 3- and 12-month graft survival rates in patients transplanted during holidays vs. workdays or on the different weekdays, comprehending the weekend days. Such a result should be explained because the dedicated transplant surgical teams of the centers involved in the study are on call only for the transplant procedures and not involved in other types of surgical emergencies during holidays and nights. Moreover, no changes in the surgical teams that performed the operations on weekdays or holidays were present, with the same equips performing the procedures no matter on the day of the week.As for the reduction of LT during the holidays, our experience is in line with previous studies. The increase in organ discard rates has been advocated as a potential explanation of this phenomenon during off-days, even after adjustment for organ quality. Carpenter et al. report that liver graft non-usage was 11% higher on the weekend than on weekdays . Mohan eUnfortunately, due to the retrospective nature of our study, we were not able to investigate the discard rates during the holidays. However, we noted that a comparable rate of marginal grafts was used during the workdays and holidays , therefore suggesting that the reduction in the number of transplants was not only attributable to an increased organ discard, but it probably represents a combination of phenomena also comprehending the reduction in the number of donor procurements caused by the extra-day off before the holiday.Another concern observed in our series was the evident decline of transplants performed on Mondays, even when compared with the procedures performed on Sundays. This phenomenon, already observed in other geographical areas, has been defined as the “transplant Monday blues” . A straiOrgan donation requires respect for strict protocols involving many specialists and hospital services, representing a resource- and time-consuming procedure. Hence, postponing the beginning of the donation process on Monday, during which the health care hospital system does not suffer from limited resources, can be considered an alternative option. Moreover, it must be considered that donors are frequently from hospitals bereft of required specialists  that must be called from other district hospitals and are at the same time on call for the emergencies service of their specific specialties. Lastly, another issue explaining the decrease of donations during the weekend is the higher mortality observed during these days in emergency patients admitted for stroke, heat acute disease, and trauma, consequently reducing the available donor pool , 31–33. This is the first study reporting an Italian series on this topic. Although the analysis is limited only to the surgical activity of the transplant centers of the Universities of Rome, in the authors’ opinion, the results may be representative of the impact of holidays on liver procurement and transplantation in the Italian setting. The study presents some limits. First, the study is retrospective and multi-centric. Second, no data have been collected on the number of potential donors and the rate and reasons for graft discard on different weekdays or during the holidays.In conclusion, LT procedures reduce their numbers during the holidays and on Mondays. The results are similar no matter the day the transplant is performed. An improvement of the resources should be applied during the weekends and holidays to improve the number of available organs to reduce the critical gap between the request for transplantation and the pool of available organs. Further studies investigating the impact of the different weekdays on the discard rate are indeed required.


IntroductionNowadays, cosmetic demands are the first reason to visit dental clinic. However, most ceramic prostheses need an excessive removal of the dental structure, whether for full crowns or veneer preparation. With the innovation in ceramic materials, high translucent zirconia that demands minimal preparation with high aesthetic results was used for computer-aided design/computer-aided manufacturing (CAD/CAM) Full ceramic crown fabrication. The objective of this study was to compare the translucency properties of CAD/CAM full ceramic crowns fabricated from glass ceramics (E.max) and high translucency zirconia .Material and methodsThe sample consisted of 60 full ceramic crowns divided into two groups; the first group consisted of 30 IPS E.max CAD/CAM full ceramic crowns, while the second one consisted of 30 high translucent zirconia CAD/CAM full ceramic crowns. Translucency for both groups was evaluated directly after cementation by observing the blue light passing through the prostheses. Pearson Chi-Square test was used to study the difference in translucency between the two study groups.ResultsIPS E.max CAD showed a higher translucency compared to lava plus high translucency zirconia; in addition, this difference was statistically significant (p=0.028).ConclusionWithin the limitation of this study, we found that the translucency of dental ceramic was affected by the ceramic material. As IPS E.max CAD was significantly higher in terms of translucency compared to High Translucent Zirconia. Nowadays, cosmetic demands are the first reason to visit a dental clinic, and full ceramic prostheses usually meet these demands . Dental Feldspathic ceramic was used as a material for manufacturing fixed prostheses for long periods due to its high aesthetic properties and results . NeverthRecently, new aesthetic porcelain materials have been used, such as high translucent zirconia , which is a versatile material and can be utilized for single anterior and posterior restorations, for bridges up to three units, and for implant crowns, and characteristic by high biocompatibility and high aesthetic properties . Its traHigh translucent zirconia can afford 1,500n of fracture forces with a preparation thickness of 0.6 mm, while lithium di silicate needs a preparation thickness of 1.2 mm to afford the same forces. Thus, High translucent zirconia is considered a conservative prosthesis that needs minimal preparation .Fabricating prostheses by Computer-aided design/computer-aided manufacturing (CAD/CAM) techniques have many advantages over traditional laboratory procedures, as it is faster, easier to use, and saves more time by skipping waxing, casting, pouring, and firing procedures. In addition, CAD/CAM systems reduce technical problems and produce a precise prosthesis with a lower possibility of fracture, which refers to the absence of pores in its inner surfaces .Several studies have evaluated the translucency properties of E.max full ceramic crowns fabricated using CAD/CAM techniques. However, minimal studies have mentioned Lava plus high translucent zirconia crowns, therefore, this study aimed to compare the translucency properties of CAD/CAM full ceramic crowns fabricated from glass ceramics and high translucency zirconia.Sample descriptionThe study sample consisted of 60 CAD/CAM full ceramic crowns divided into two groups: the first group consisted of 30 CAD/CAM full ceramic crowns fabricated from glass ceramic (IPS e.max). Similarly, the second group consisted of 30 CAD/CAM full ceramic crowns fabricated from high translucent zirconia.G-Power software version 3.1.9.4  was used to calculate the sample size. A significance level of 0.05 and a power of 95% were determined. As a result, a sample size of 30 patients was required for each group.Patient recruitmentCrowns were performed for patients attending the Department of Fixed Prosthodontics of Damascus University Dental School who suffer from aesthetic problems in their teeth in the anterior and premolars regions.The inclusion criteria were as follows: patient's age ranged from 18 to 50 years old, an obvious indication for full ceramic crowns  in addition, absence of gingival and the periodontal inflammatory, normal or near normal anterior occlusion bite, absence of non-functional habit and good oral hygiene.The exclusion criteria consisted of having a big modification on the occlusion bite, loss of more than two-thirds of the dental walls, i.e., the need to place a metal post and core under the final crown, and the loss of alveolar bone support for the root.The main complaint and the patient medical and dental history were taken. Patients were questioned about their medical history and medications. Patients underwent intraoral and extraoral examinations. In addition, intra-oral pictures and pictures of the smiling status were taken. Furthermore, each patient was asked about the expected aesthetic result. This information was filled in a specific form created for this study. Planmeca Romexis® Smile Design software was used to show the final results to the patients. Finally, patients' consent was obtained.Teeth preparation and prosthetic stageTeeth were prepared to receive full ceramic crowns as follows: for E.max crowns, guidance grooves with a depth of 1mm were made by depth cutting bur , then flat end cylinder bur was used to complete the occlusal surface preparation; for axial walls preparation, black round end taper bur (1mm) was used. Finally, a red round-end taper bur (1mm) was used to determine the shoulder finish line. As well as the same steps were done for zirconia crowns. However, the preparation thickness ranged between 0.6 and 1mm for all surfaces, with 0.5mm thickness of the semi-shoulder finish line.The gingiva was retracted using the appropriate size of the gingival retraction cords according to the gingival biotype (thick/thin) of each patient in order to determine the finish line area. After that, final impressions were taken using additional silicone . On the other hand, alginate was used to take the impression of the opposite arch. The occlusal bite was registered by the wax bite. The impression was poured using gypsum type IV .At the end of this session, a suitable shade was chosen by the dentist using Vita 3D shade guide. That shade was documented after getting the patients' approval; then temporary prostheses were made using intra-oral acrylic .Fabrication of the full ceramic crowns using the CAD/CAM techniqueThe first step was applying a powder spray on the surfaces of the dies for the scanning process, which was performed using an extraoral scanner , a “3D in Lab” designing program, and a computer. All of these subjects were connected to the laser scanner device (CCD), and after that, a 3D picture of the cast model was obtained on the computer screen.After determining the finish line at the digital virtual model with a 40-micron virtual luting cement space and finishing the shape designing process, the milling process was divided into two stages. Stage one included milling the IPS E.max block using a “wet 360c” milling device (Imes-core company), while stage two included milling the Lava plus discs using a “Dry 250i” device (Imes-core company).After completing the milling process, we obtained a zirconia disc containing the milled prostheses connected by zirconia wedges, and the same applies to the prostheses made of lithium disilicate, each crown was then separated using specific separating disks, whereas the crowns were unhardened completely and have a blue color shade.A hardening oven (Programt P500) was used to start the crystallization process for E.max crowns, with the heating degree up gradually to prevent any following shrinkages. When the hardening step was done, glass ceramic (IPS e.maxceram) was applied over all crown surfaces.Zirconia crowns were placed in a special crucible filled with zirconia granules to support them during their shrinkage resulting from condensation; after that, they were inserted into the condensing oven and remained for 9 hours and 20 minutes, the oven temperature was raised by 8 degrees per minute with stability for half an hour until it reached 900°, then it gradually raised again at a rate of 3 degrees per minute until it reaches 1,530° and remains constant for two hours at this temperature. At the end of the sintering process, it returns and decreases to room temperature. Sandblasting was carried out on the inner surface of these crowns, using aluminum oxide granules of size 110 microns and a pressure of 2 bar for 30 seconds, taking care not to approach the edges.The final step for both groups was glazing, which was carried out using a glazing kit from Dental Direct company, the material was applied using a special brush, then the prostheses were placed in the thermal oven for 30 minutes at a temperature of 920°.Final cementationBefore final cementation, provisional prostheses were removed, and full ceramic crowns were trying-in by examining the internal fit, interproximal points, high occlusal points (if any), and color matching with adjunct teeth and prosthesis. Furthermore, patients' approval of the aesthetic results was taken.For IPS E.max crowns, etching with hydrofluoric acid (9%) was applied for 90 seconds, then washed and dried, double bonding agent was applied (MonoBond S) for 60 seconds and extended by airflow only.For Lava plus high translucent zirconia crowns, sandblasting for the inner surfaces was done using a Pencil sanding tool for one minute, after which it was washed with running water for one minute, then primer containing MDP particulars (Bisico) was applied for 30 seconds according to the manufacturing company instructions.In order to control saliva and ensure the complete dryness of the workspace, isolation was done using cotton rolls and a high-pressure suction. All surfaces of the prepared teeth were etched using phosphoric acid (37%) for 30 seconds, washed, and dried, then the chalky appearance was seen. The next step was to apply the dentin bonding agent (Tetric-N Bond) and spread it by a slight airflow only; light curing resin cement (Variolink N) was also put and spread on the whole inner surface of the crowns; after that, crowns were placed above the abutment surfaces.Resin cement was light cured for 3-4 seconds only to easily remove the excess cement with dental floss for the proximal surfaces and by a dental probe and surgical blade type 12 for the buccal and palatal surfaces.Full curing was done by applying the light curing device for 60 seconds on each side. Finally, margins were finished using extremely soft diamond finishing burs and soft abrasive strips for the proximal areas Figures , 2.Translucency assessmentTranslucency was assessed by applying the blue light emission by dental light curing unit, from the palatal surface of the measured tooth to evaluate the prosthesis translucency as if the light is visible from the buccal surface, the prosthesis is considered to be translucent, while if the light is not visible, the prosthesis is considered to be slightly translucent or opaque according to the amount of the passing light. The evaluation was done directly after cementation. Statistical analysisData were collected and exported to Microsoft Excel 2013 (Microsoft Corporation). Then, statistical tests were conducted using Statistical Package for the Social Sciences (SPSS) version 26 , with a significance level of 0.05. Pearson's Chi-Square test was used to study the difference in translucency between the two groups.Sample descriptionThe sample consisted of 15 patients . Patients' ages ranged from 24 to 45 years, with an arithmetic mean of 35.9 years and a standard deviation of 6.1 years .Several materials were used to achieve the best esthetic results with different types of prostheses as fixed bridges, full crowns, and veneers. Thus, with the development of glass ceramics, some materials became more popular, such as lithium disilicate . HoweverThe sample consisted of 15 patients who attended the Department of Fixed Prosthodontics of Damascus University Dental School and suffered from aesthetic problems in their teeth appearances in the interior and premolars region% 66.7 of the patients were female, and generally, they are the most interested in having an esthetic appearance. In a cross-sectional study conducted at the Lithuanian University of Health Sciences (LSMU), it was reported that females were the most interested in smile shape and appearance and most demanding the esthetic aspects [Translucency can be described as the quality of light passing through a material; thus, translucent material is made up of components with different indices of refraction. When light encounters a material, it can interact with it in several different ways . These iIn this study, IPS E.max showed a higher translucency compared to lava plus high translucency zirconia; in addition, this difference was statistically significant. The different translucency shown in both groups may be due to the different shade colors of the cemented prosthesis, as the shade color was chosen for each patient according to the color of his natural teeth. In addition, the buccal-lingual distance differs between teeth as well as between patients with the same tooth, which affects the distance traveled by the light.The results of our study agreed with Church's study, which reported a higher translucency for E.max compared to different types of zirconia with different thicknesses. In addition, the translucencies of the zirconia materials were similar at each thickness . As wellHigh translucency zirconia is a tetragonal polycrystalline zirconia partially stabilized with 3mol-% Yttria engineered for high translucency and utmost strength. It has a lower Alumina content of 0.1%, optimally distributed within the material for maintaining aging stability, whereas Lithium disilicate (LS2) is classified as a glass-ceramic, in the class of particle-filled glass materials .On the other hand, our results disagreed with Baldissara's study, which showed significantly higher translucency by using multilayered high translucent zirconia compared to IPS E.max . This stWithin the limitation of this study, we found that the translucency of dental ceramic was affected by the ceramic material as IPS E.max CAD was significantly higher in terms of translucency compared to High Translucent Zirconia when using it for interior and posterior restorations. This means that even with different ceramic thicknesses, IPS E.max showed higher translucency propriety.


Twin–twin transfusion syndrome (TTTS) is characterized by unequal hemodynamics between the twins. We aimed to assess preoperatively the difference in umbilical vein flow (UVF) between the recipient and donor monochorionic diamniotic twins and evaluate the change in UVF following laser surgery in both twins.Z‐score by a calculator created using gestational age as an independent variable. Z‐score values were converted into centiles, which were evaluated statistically. Median differences in UVF/kg centile values were adjusted for TTTS stage and presence of arterioarterial anastomoses.This was a retrospective cohort study of differences in UVF that occurred following laser surgical treatment of TTTS. Sonographic assessment of the umbilical vein before and 24 h after fetoscopic laser surgery for TTTS was performed. Umbilical vein diameter and time‐averaged maximum velocity were measured, and UVF per kg (UVF/kg) was converted into a vs donor twin was 17.9% (−17.1% to 57.6%), P < 0.0001. The adjusted median difference in UVF/kg centile between the postoperative vs preoperative period among recipients was 2.2% (−10.8% to 13.8%), P < 0.0001, while the adjusted median difference among donors was 27.3% (8.2%–34.6%), P < 0.0001.The study population consisted of 363 TTTS patients. The adjusted preoperative median difference in UVF/kg centile between the recipient The preoperative difference in UVF between the recipient and donor twins confirms the pathophysiology of TTTS. Postoperatively, the substantial increase in UVF of the donor twin and the relatively small increase in UVF of the recipient twin confirm that ablation of the vascular communications resulted in rapid improvement in perfusion of the donor twin. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. What are the novel findings of this work?Z‐score calculator, which uses gestational age as an independent variable, to evaluate changes in umbilical vein flow (UVF) following treatment. We demonstrated a significant difference in the UVF between recipient and donor twins, confirming unequal intertwin blood flow as the cause of TTTS. We also observed a significant postoperative increase in UVF of the donor twin, confirming fetoscopic laser surgery as an effective treatment on a pathophysiological level.In this large study on monochorionic diamniotic twin pregnancies treated with laser surgery for twin–twin transfusion syndrome (TTTS), we employed a newly designed What are the clinical implications of this work?This study sheds light on the preoperative difference in UVF per kg between recipient and donor twins in TTTS. This paves the way for future studies to evaluate the role of this difference in UVF per kg in predicting TTTS, as a prediagnostic step or an estimate of severity.Twin–twin transfusion syndrome (TTTS) occurs in approximately 10% of monochorionic diamniotic (MCDA) pregnancies, and carries a significant risk of perinatal morbidity and mortality if left untreatedAlthough different management options for TTTS have been described, fetoscopic laser ablation of communicating vessels remains the first‐line treatment for Quintero Stage‐II, ‐III and ‐IV TTTSZ‐score calculator that converts Z‐scores to centiles as a clinical tool to measure changes in UVF before and after laser surgeryGiven that the umbilical vein (UV) is the only conduit of blood from the placenta to the fetus, assessment of its pre‐ and postoperative flow may help understand the pathophysiology of TTTS. Previous studies have demonstrated a significantly higher UV flow (UVF) of recipients compared with donors in TTTSThe aims of this study were (1) to describe the difference in UVF between the recipient and donor in MCDA twin pregnancies complicated by TTTS prior to laser surgery and (2) to evaluate the change in UVF following laser surgery in both twins.Z‐score calculator was computed . Incomplete laser surgery was defined as inability to perform laser photocoagulation of all intertwin vascular anastomoses. Reasons for incomplete surgery may include poor visualization of vascular anastomoses secondary to discolored amniotic fluid (e.g. due to pre‐existing subchorionic hematoma or bleeding from uterine trocar insertion), challenging placental location and maternal or fetal instability precluding ability to complete surgery. Each patient underwent a detailed preoperative ultrasound examination, which included evaluation of cervical length, amniotic fluid volume, fetal morphology, biometry, estimated fetal weight (EFW) and Doppler flow of the umbilical artery, UV and ductus venosus. The preoperative ultrasound examination was performed 1 day prior to surgery, and the postoperative scan was conducted on postoperative day 1. EFW was not remeasured postoperatively.This was a retrospective cohort study of changes in UVF following laser surgical treatment of MCDA twin pregnancies complicated by TTTS. The study population consisted of all patients diagnosed with TTTS, including Stage‐I TTTS patients, who underwent fetoscopic selective laser photocoagulation of communicating vessels (laser surgery) between 18 and 26 gestational weeks at our center  from February 2010 to May 2020. Laser surgery was offered routinely to patients with symptomatic or unstable Stage‐I TTTS (e.g. patients with symptomatic polyhydramnios or short cervix). Stable patients were counseled regarding the lack of consensus with respect to optimal first‐line management of stable Stage‐I TTTS, as detailed in a recent articleUV parameters were measured from the free loop of the UV at or near the abdominal wall insertion site. Color Doppler was activated to visualize flow and measure the time‐averaged maximum velocity (TAMX). The same section of the sampled UV, adequately zoomed, was used to measure the UV diameter (UVD) from the anterior inner to the posterior inner wall perpendicular to the beam of ultrasound Figure . All ang2) and TAMX (cm/s) as follows: UVF = 3.14 × (UVD/2)2 × 0.5 × 60 × TAMX. UVF/kg was derived by dividing the UVF by the EFW in kg. UVF/kg Z‐scores and the corresponding centiles (UVF/kg centiles) were calculated using a Z‐score calculator with a range of 18–26 gestational weeks, created using GA as an independent variable in a population of normal singleton fetusesAssuming parabolic flow in a straight lumen, UVF (mL/min) was calculated based on the cross‐sectional area . This difference was also calculated for the postoperative period for completeness. For Analysis 2, the difference between preoperative and postoperative measurements was calculated separately for donors and recipients (postoperative minus preoperative). These differences were tested and found to vary with Quintero stage and presence of arterioarterial (AA) anastomoses on bivariate analyses Tables ; they din (%) or median (range). Analysis was performed using SAS statistical software . The study was approved by the University of Southern California Health Sciences Campus institutional review board .Data are presented as Of 633 patients diagnosed with TTTS and treated with laser surgery during the study period, 270 were excluded, resulting in 363 patients included in the final study population  vs 8.2% ) mL/min/kg and 79.9  mL/min/kg, respectively, with a median difference between the recipient and donor of 20.12  mL/min/kg, R2, 0.1424, P < 0.0001) (data not shown). When adjusted for Quintero stage and presence of AA anastomoses, the preoperative median difference in UVF/kg centiles between the recipient and donor was 17.9% , P < 0.0001.Bivariate analysis demonstrated an association of the preoperative differences in UVF/kg centiles with Quintero stage Table  and presP = 0.1334. The median postoperative UVF/kg centile of the recipient and donor twins was 40.5%  and 54.1% , respectively, with a median difference between the recipient and donor of −5.2% , P = 0.0021. When adjusted for Quintero stage and presence of AA anastomoses, the postoperative median difference in UVF/kg centiles between the recipient and donor was −7.2% , P < 0.0001.The median postoperative UVF/kg of the recipient and donor was 109.8  and 110.1  mL/min/kg, respectively, with a median difference between the recipient and donor of −5.26  mL/min/kg, P = 0.0848 and 31.6  mL/min/kg, P < 0.0001, respectively. The median UVF/kg centile of the recipient twin increased from 31.6%  to 40.5%   to 54.1%  , R2 value was 0.0290 (P = 0.0057) for recipients and 0.0230 (P = 0.0150) for donors (data not shown). When adjusted for Quintero stage and presence of AA anastomoses, the median difference in recipient UVF/kg centile between the postoperative and preoperative period was 2.2% , P < 0.0001. When adjusted for Quintero stage and presence of AA anastomoses, the median difference in donor UVF/kg centile between the postoperative and preoperative period was 27.3% , P < 0.0001.The median difference in UVF/kg centiles between the postoperative and preoperative period for both recipients and donors was associated with Quintero stage Table  and presThe pathophysiology of TTTS is attributed to imbalance in blood flow between monochorionic twins, which occurs due to shunting of blood through vascular communications in the common placenta. The UV is the only conduit of blood from the placenta to the fetus; therefore, any fetoplacental hemodynamic changes are reflected by its flow parameters. In TTTS, the discrepancy in UVF between the recipient and donor twins reflects the unidirectional net flow of blood from one twin to the other. The findings of this study are consistent with this theory, as recipient twins had a significantly higher UVF/kg centile compared with donors prior to laser surgery for TTTS. At the assessment 24 h after corrective laser surgery, the UVF/kg centile of recipient twins remained relatively stable, while the UVF/kg centile of donor twins increased significantly. These findings suggest rapid correction of blood‐flow imbalance following laser surgery.et al.n = 32) and Ishii et al.n = 41) directly measured time‐averaged mean velocity, also referred to as intensity‐weighted mean velocity2) × 60. In contrast, we measured TAMX to derive the time‐averaged mean velocity (TAMX × 0.5), assuming parabolic flow, and calculated UVF (mL/min) as follows: TAMX (cm/s) × 0.5 × mean cross‐sectional area (cm2) × 60. Figueras et al.Gratacós et al.et al.vs 151 mL/min/kg, P < 0.0001vs 173.2 mL/min/kg, P < 0.0001et al.P < 0.0001) 1 day after surgery, while recipients had a non‐significant postoperative increase in median UVF/kg (260–283 mL/min/kg). Likewise, Ishii et al.P < 0.0001) and a non‐significant change in recipients , which is concordant with our findings.Although our UVF/kg values are not directly comparable to those reported by Gratacós Placental territory discordance is thought to be the cause of sFGR in monochorionic pregnancyvs 0.2%, P < 0.0001)  Table . In otheZ‐score calculator, which converted Z‐scores to their corresponding centiles and accounted for both GA and EFWThis study has several strengths. The parameter we used to compare differences in UVF (UVF/kg centile) was derived from a et al.Z‐score calculator presented a potential limitation because it was derived using a singleton‐fetus population and was applied to our twin‐fetus population. Despite the abovementioned limitations, our findings are not only concordant with prior published studies, but are also physiologically plausible.The limitations of this study include potential variability in data accuracy given the operator‐dependent nature of sonographic measurements. Different sonographers took measurements of UV parameters over a period of 10 years, and while the measurement technique was the same, operator‐dependent variability is inevitable. An additional limitation of this study is that all ultrasound UV parameters were acquired from the free‐loop portion of the UV. While this technique is in line with that utilized by Ishii The preoperative difference in UVF between the recipient and donor twins confirmed that unbalanced intertwin blood exchange is a characteristic of TTTS. Postoperative measures that demonstrated an increased overall median UVF in donors and overall unchanged median UVF in recipients confirmed that the ablation of vascular communications resulted in rapid improvement of perfusion in donor twins and a relatively stable perfusion of recipient twins. Future studies exploring the effect of AA anastomoses and sequential surgical technique on UVF parameters may offer a better understanding of pre‐ and postoperative hemodynamic fluctuations in TTTS. The performance of the preoperative difference in UVF/kg between the recipient and donor twins in predicting TTTS, as a prediagnostic step or estimate of severity, should be investigated further to assess its potential clinical utility.