At longer reaction times, starch laurates having higher degrees of substitution (DS) were obtained. While starch laurates are the major products of transesterification, relatively low-molecular-weight byproducts (1%) were detected and could be hydrolyzed starches based on gel permeation chromatography results. Contact angle measurements confirmed the relatively high hydrophobicity of the modified starches compared with that of native starch. The modified starches were then employed to prepare water-based adhesives on paper . Notably, the shear strength of the esterified starch adhesives appears to be independent of the DS of esterified samples, hence the transesterification reaction times. Additionally, the shear strength of water-based adhesives (0.67–0.73 MPa) for bonding to paper substrates is superior to that of two other commercially available glues by a factor of 10 to 80 percent.Instead of using finite petroleum-based resources and harmful additives, starch can be used as a biodegradable, low-cost, and non-toxic ingredient for green adhesives. This work employs K Starch is a low-cost, non-toxic, renewable, and biodegradable resource that is widely used in food, medicine, and agriculture. It consists of two biopolymers: amylose and amylopectin. Amylose is made up of long helical chains, while amylopectin has a branched structure . In addi3PO4; Sigma-Aldrich, Munich, Germany), dimethyl sulfoxide , methyl laurate , chloroform-d , ethanol, and chloroform . Deionized (DI) water was employed as a solvent. Cassava starch  was purchased from a local market . The used as-received chemicals were potassium phosphate (Kw/w) of DMSO. The starch was then gelatinized at 90 °C for 3 h before 2% (w/w) K3PO4 was added, followed by methyl laurate (1:3 molar ratio of starch: ester). The mixture was then heated at 110 °C for different time periods  and on cooling. Then the brownish product was washed with ethanol before being dissolved in chloroform and precipitated by being added to ethanol. Finally, the modified starch was dried at around 80 °C in the oven overnight.In a general procedure, cassava starch (15 g) was added into a 250 mL round-bottom flask with 150 mL (10% Ten grams of cassava (or modified starches) was dissolved in DI water in the weight by volume ratio of 1:20 (starch: water) and heated to 70–90 °C for the gelatinization of each sample. After the starch was gelatinized, the volume of each aqueous starch solution was adjusted to 200 mL and cooled to room temperature.1H-NMR spectroscopy. Starch laurate samples were dissolved in d6-DMSO and heated at 50 °C until clear solutions were obtained. 1H NMR spectra were measured on a Bruker Ascend NMR spectrometer 400 MHz  at 23 °C with 32 scans. The DS values of the modified starches were calculated using the following equation [A is the peak area from the integration from the methyl signals, and C is the peak area from the integration of the proton signals from the anhydro glucose unit.Information about the chemical structure and DS value of modified starches was obtained using equation :(1)DS=A×v/v) DMSO (HPLC grade) at a flow rate of 0.15 mL/min at 60 °C. The retention time was set at 100 min, with the signal being monitored using an RI detector and quantified using LabSolutions (Shimadzu) software. Injection volumes for starch samples were 60 µL after a 10-fold dilution, although that used for standard dextran was 25 µL (10 mg/mL). Separation of starch components was performed on the principle of size exclusion using GPC, which was performed using an OHpak SB-805 HQ column (6 × 300 mm) with mobile phase 75% ; column, TSKgel G5000PW (300 × 7.5); system, DI water at a flow rate of 0.5 mL/min with an RI detector; injection volume, 50 µL; column temperature, 80 °C; and detector temperature, 50 °C.The morphology of starch and starch laurate was observed using a JSM-IT500, Jeol, scanning electron microscope . The samples were placed on a stub with double-sided adhesive tape, and micrographs were recorded at various magnifications.−1 and 64 scans. Spectra were recorded over a region of 4000–650 cm−1 [Modified starch and native starches were analyzed by FTIR spectroscopy on a Nicolet Summit Pro instrument  in the attenuated total reflectance (Diamond-ATR) mode using a resolution of 4 cm650 cm−1 .−1 over a spectral range of 3700 to 50 cm−1.Raman spectra were collected on a Horiba XploRA PLUS instrument, Japan (combined with LabSpec6 software) equipped with a 785 nm laser providing 28.7 mW of power. The spectra were recorded at a resolution of 5.44 cmThe sample  was added to an Eppendorf tube followed by 0.6 mL of hot (70 °C) water. After mixing (vortex), the tube was kept in a water bath shaker at 70 °C for 1 h. After this time, the tube was centrifuged at 4000 rpm for 15 min to separate the starch and water phase. The water was removed, and the starch was dried in an oven at 65 °C overnight prior to being weighed [The wettability properties of starch powders were estimated by direct observation of the contact angle of a water drop, approximately 5 μL deposited on the surface of the compacted starch powder by using a contact angle meter . The Young–Laplace equation fitting method was used, and the results were evaluated  by using the Young–Laplace theory .Simultaneous thermogravimetric analysis (STA) was carried out on a NETZSCH STA 449 F5 Jupiter instrument  using about 5–10 mg of the sample. The sample was placed in an alumina crucible and heated from 25 to 800 °C with a heating rate of 10 °C/min under nitrogen atmosphere, with a flow rate of 50 mL/min. In addition, differential scanning calorimetry (DSC) was carried out by using a Q200 V24.11 Build 124 TA instrument . In a typical measurement, approximately 0.5 g of the sample was dispersed in DI water (the ratio 1:4 = sample: water) and stirred for 1 h. A small amount (5 mg) of dispersion was then placed in the pan and heated from 25 to 250 °C (a heating rate of 5 °C/min) under nitrogen atmosphere to observe the gelatinization temperature.The viscosities of starch-based adhesives were determined in triplicate at 30 °C using a Brookfield viscometer (DV-II)  with spindle no.5 at 20 rpm. Values are expressed in mPa·s in this work.Lap-shear strength, referred to as bonding strength in this study, was obtained for starch-based adhesives following a modification of the ASTM D1002 method. For this, a paper substrate was cut into 100 mm × 25 mm strips. The adhesive (0.04 g) was then applied to a 13 mm × 25 mm region of one paper strip, and then this was overlapped with an identically sized portion of a second paper strip. After the glue dried, the bonding strength was obtained using a universal testing machine  .(4)Sheap-values ≤ 0.05).The results were reported as mean value and standard deviation (SD). Descriptive statistics was calculated using version18 of the predictive analytics software (PASW) program [1H NMR spectra of native cassava starch and starch laurate 10 h in The values of the degree of substitution were calculated by the mentioned Equation (1). The 6 Da) was present. Based on the GPC results, the starch laurates having a higher molecular weight than that of the native cassava starch suggested the achievement of the modification of hydroxyl groups to ester groups. In addition, the GPC peaks around 26 min likely correspond to hydrolytic products resulting from the hydrolysis of polysaccharide by K3PO4. Transesterification and hydrolysis are in competition with one another. w) of all samples, while the reaction times of 4 h and above are sufficient to achieve starch laurates . Furthermore, the results from the DMSO system present that there is an extra new peak in starch laurate samples (29 min) in SEM images  showed t−1) in all modified starch confirmed the successful transesterification of the starch. In addition, the C–H stretching vibrations corresponding to the alkyl groups from the laurate fatty acid ester chain are present at around 2920 and 2850 cm−1. The broad band in the region of 3000–3600 cm−1 is attributed to hydroxyl vibration and decreased in modified starch samples, suggesting the conversion of hydroxyl groups to ester groups. Characteristic peaks (C–O stretching) from the starch polysaccharide backbone are observable at 900–1250 cm−1 in all samples [ samples .−1, which correspond to the skeletal vibrations of the pyranose ring in the starch glucose units. A peak between 920 and 960 cm−1, a result of vibrations in the C–O–C or the 1,4 glycosidic linkages [−1, is of lower intensity in starch laurates. A peak at approximately 2920 cm−1, diagnostic of C–H stretching, can be observed in all starch samples [Raman spectra in linkages , occurs  samples .The hydrophobicity of starches was determined by measuring the contact angle of water on the pelletized samples. An angle lower than 90° is considered hydrophilic, between 90° and 120° is considered hydrophobic, and materials exhibiting angles greater than 120° are termed superhydrophobic . Due to Due to their solubility in water and ability to swell, starch laurate samples were utilized to prepare water-based adhesives. The gelatinized aqueous starch laurate samples showed moderately low viscosity, which ranged from 1280 to 2280 mPa·s b. On thep > 0.05). The failure mode after the shear strength measurement indicated cohesive failure in paper substrates due to the higher bonding strength between the adhesive and adherend than their individual strength [Shear strength, which represents the ability of adhesives to bond surfaces together, is a significant factor in determining the usefulness of such products. In a previous work, paper glues were made from whey protein, and various additives show quite high shear strengths (1.07–1.35 MPa) ,32. In tstrength . Hydrogestrength . From thAccording to 3PO4 catalyzed transesterification of cassava starch in the presence of methyl laurate, were employed to prepare water-based adhesives to bond papers. A low DS of 0.22, from a maximum possible DS of 3.0, was obtained. Aqueous GPC analyses confirmed the successful modification of cassava starch. The enhanced hydrophobicity of starch laurates suggested the improved water resistance of modified starch adhesives. The starch laurate water-based glues exhibit superior adhesion strength for paper compared with commercially available paper glues. Thus, the reactivity of methyl laurate, which was determined in this study, and the enhanced hydrophobicity of starch laurates can lead to the development of environmentally friendly adhesives with superior water resistance and adhesion strength for paper. Further investigation on the effects of humidity on the adhesives’ bonding strength can be carried out to add more confidence that hydrophobic starches  are suitable raw materials for the production of water-based adhesives with enhanced water resistance compared with native starches.Starch laurates, produced via a K


A decision tree model was performed to determine rules to highlight the different hierarchization and interactions between these classifiers with a higher performance than multiple logistic regression (p<0.001). The stiffness index could be an integrator of CV risk factors and participate in future CV risk management evaluations for preventive strategies. Decision trees can provide accurate and useful classification for clinicians.Arterial stiffness, measured by arterial stiffness index (ASI), could be considered a main denominator in target organ damage among hypertensive subjects. Currently, no reported ASI normal references have been reported. The index of arterial stiffness is evaluated by calculation of a stiffness index. Predicted ASI can be estimated regardless to age, sex, mean blood pressure, and heart rate, to compose an individual stiffness index [(measured ASI–predicted ASI)/predicted ASI]. A stiffness index greater than zero defines arterial stiffness. Thus, the purpose of this study was 1) to determine determinants of stiffness index 2) to perform threshold values to discriminate stiffness index and then 3) to determine hierarchical associations of the determinants by performing a decision tree model among hypertensive participants without CV diseases. A study was conducted from 53,363 healthy participants in the UK Biobank survey to determine predicted ASI. Stiffness index was applied on 49,452 hypertensives without CV diseases to discriminate determinants of positive stiffness index  from negative index . The input variables for the models were clinical and biological parameters. The independent classifiers were ranked from the most sensitives: HDL cholesterol≤1.425 mmol/L, smoking pack years≥9.2pack-years, Phosphate≥1.172 mmol/L, to the most specifics: Cystatin c≤0.901 mg/L, Triglycerides≥1.487 mmol/L, Urate≥291.9  Arterial stiffness (AS), measured by arterial stiffness index (ASI), could be considered to be a main predictor in target damage of organs among primary hypertensive subjects . AS is cHowever, individually, only ASI measure shows no relevant information. Numerous factors were strongly associated with AS, including age, gender, blood pressure (BP), and heart rate (HR) . An indeInvestigation of the potential determinants of increased AS in a large hypertensive population could provide a better understanding of consistent data to prevent CV risks. Machine learning, such as the decision tree, is a retrospective computational method to highlight information from a large dataset. Decision tree models could be one of the major algorithms in data mining tools for the management prevention of CV disease –21. A deThus, the purpose of this study was 1) to determine determinants of stiffness index 2) to perform threshold values to discriminate stiffness index and then 3) to determine hierarchical associations of the determinants by performing a decision tree model among hypertensive participants without CV diseases.https://www.ukbiobank.ac.uk/learn-more-about-uk-biobank/about-us/ethics.The UK Biobank is a prospective cohort for the investigation, prevention, diagnosis and treatment of chronic diseases, such as CV diseases in adults. Between, 2006 and 2010, 502,478 Britons across 22 UK cities from the UK National Health Service Register were included. The cohort was phenotyped and genotyped, by participants who responded to a questionnaire; a computer-assisted interview; physical and functional measures; and blood, urine, and saliva samples . All parSystolic and diastolic blood pressures  were measured twice at the assessment centre by the use of an automated BP device , or manually by the use of a sphygmomanometer with an inflatable cuff in association with a stethoscope if the blood pressure device failed to measure the BP or if the largest inflatable cuff of the device did not fit around the individual’s arm .The participant was sitting in a chair for all the measures. They were carried out by nurses trained in performing BP measures on the left upper arm . MultiplFor SBP, the following algorithm was performed:For DBP, the following algorithm was performed:These adjusted BP values were used for all calculations, including mean BP calculation .Mean BP was calculated as:™, CareFusion, USA) to the rested volunteer’s finger . Volunteers were asked to breathe in and out slowly five times in a relaxed fashion and readings were taken over 10–15 seconds. The carotid-to-femoral pulse transit time was estimated from the dicrotic waveform as the time difference between a forward compound when the pressure is transmitted from the left ventricle to the finger and a reflected or backward compound as the wave is transmitted from the heart to lower body via the aorta [Pulse wave arterial stiffness index (ASI) was estimated through a non-invasive method during a volunteer’s visit to a UK Biobank Assessment Centre. Peripheral blood volume was taken by clipping a photoplethysmograph transducer ). Current tobacco smokers were defined as participants who responded “yes, on most or all days” at the question “do you smoke tobacco now”. Smoking pack-years are calculated by physicians during examination as the reported average number of smoking packs per day divided by the total number of years of smoking during their lifetime, for never-smokers the value was zero. CV diseases were defined by heart attack, angina and stroke, as diagnosis by a doctor and reported in questionnaires. Body mass index was calculated as weight (in kg) divided by height2 (metres).Hypertension was defined as systolic blood pressure (SBP) of at least 140 mm Hg and/or diastolic BP (DBP) at least 90 mm Hg, according to guidelines by the European Society of Cardiology, and/ or antihypertensive drug used , or hype‘Healthy’ participants used for the determination of stiffness index were defined as individuals without hypertension, without diabetes mellitus, without previous cardiovascular events and without chronic kidney disease  to performed predicted ASI. All hypertensive participants without cardiovascular diseases were included in this work   to invesAmong the 53,363 “healthy” participants, parameters which modulate ASI can be evaluated independently of gender, age, mean BP and HR. A stiffness index was performed by a multivariate linear regression analysis to determine predicted ASI values based on age, gender , mean BP and HR. In the multivariate linear regression, all these parameters were significant (p<0.001). Then, an equation was derived from the multiple linear regression and was applied to the individuals to perform a predicted ASI value according to their age, gender, mean BP and HR.The stiffness index was defined as:Increased arterial stiffness was defined when stiffness index was greater than 0.The target or outcome variable consisted in two classes: one class for the positive stiffness index  and the second for negative stiffness index . Data mining detects unknown patterns or prediction rules. One of the different methods of data mining is the decision tree. The decision tree model is a non-parametric methodology which performed a tree-based classification modeling , 21. TheThe Classification And Regression Tree (CART) is a decision tree algorithm . CART isImpurity was measured by the Gini index as:Then, this data mining method decision tree randomly divides the dataset into one hundred models which have been trained for the repeated cross-validation procedure to obtain the accuracy of the model. Data mining algorithms, and particularly the decision tree, do not work with missing data. Therefore, after cleaning and preparing the dataset, 49,452 hypertensive participants without CV diseases were included in the final data analysis.Characteristics of the study population were described as the means with standard deviation (SD) for continuous variables. Comparisons between groups were performed using Student’s test for continuous variables. Pearson’s Chi2 test was performed for categorical variables. A multivariate linear regression analysis was performed with age, sex, mean BP and HR to determine the equation of the predicted ASI. Then, a forward-backward logistic multivariate regression analysis model was performed based on univariate significant covariates (p<0.05) for the difference between positive and negative stiffness index.For each independent classifier of the logistic multivariate analysis, the ability of the logistic regression models to allow discrimination was quantified by the area under the ROC curve (AUC).c) for discrimination. The thresholds of the independent variables of this logistic multivariate analysis were considered as input variables in the decision tree model. A confusion matrix was utilized to determine the performance of the decision tree process for the discrimination procedure. The accuracy and the receiver operating characteristics (ROC) curve was measured [The maximum Youden index, performed as:measured . The ROCmeasured . The aremeasured . Comparimeasured . StatistAmong the 53,363 “healthy” participants, stiffness index was performed by a linear regression analysis to determine predicted ASI values based on age, gender , mean BP and HR .Thus, predicted ASI was performed by the following algorithm:Then, stiffness index was calculated in the hypertensive population based on the determination of predicted ASI. Hypertensive participants showed a mean stiffness index at 0.0163 (0.3116) compared to value of stiffness index equal to zero for healthy participants (p<0.001) . The chaThe ten remaining independent classifiers of the forward-backward multivariate model were Alanine aminotransferase (ALT) (p<0.001), Albumin (p<0.001), Testosterone (p = 0.001), Phosphate (p<0.001), Aspartate aminotransferase (AST) (p<0.001), Cystatin c (p<0.001), smoking pack years (p<0.001), HDL cholesterol (p<0.001), Triglycerides (p<0.001) and Urate (p = 0.004) .μmol/L  was obtained by applying one-hundred-fold cross validation . The perThe decision tree model 8 rules were selected with minimal positive stiffness index rate greater than 70% and a minimal population of 20 participants for the latest node.The decision tree model presented that in a subgroup (rule 3) of smokers superior to 9.2 smoking pack-years with low levels of HDL cholesterol, Phosphate, ALT, Urate, and Triglycerides but high levels of Albumin and Cystatin C, the probability of positive stiffness index was 82.4%. In the subgroup (rule 2) of smokers superior to 9.2 pack-years with high levels of HDL cholesterol, Triglycerides, Testosterone and Cystatin c but low levels of Phosphate, Urate and AST, the probability of having a positive stiffness index was 81.8%. In the subgroup (rule 4) of smokers superior to 9.2 pack-years, with low levels of both HDL cholesterol, Phosphate, ALT, Urate, Albumin, Cystatin C and Testosterone, but with high levels of Triglycerides, the participants presented a probability of positive stiffness index at 80.1% .A stiffness index was performed based on a predicted ASI calculated by a linear regression model in an “healthy” with age, gender, mean BP and HR , 42, 43.A decision tree model was performed to investigate the interaction of the different thresholds of independent factors correlated with stiffness index . A decision tree is a machine learning methodology that has several advantages, such as the ability to handle nonlinear relationships, creating rules, and being easy to interpret , 45. Nonμmol/L, ALT≥22.13 U/L, AST≤32.5 U/L, Albumin≤45.92 g/L, Testosterone≥5.181 nmol/L.The large sample of the UK Biobank allows us to add different biological parameters which are not measured in routine clinical practice for arterial stiffness, such phosphate and Cystatin C. Thus, by these results, the interest of decision trees is double: showing non-linear relationship and hierarchization of covariates and a higher accuracy compared to standard statistical models. Ten independent factors were highlighted in the logistic multivariate analysis. The ten independent classifiers were ranked from the most sensitives: HDL cholesterol≤1.425 mmol/L, smoking pack years≥9.2pack-years, Phosphate≥1.172 mmol/L, to the most specifics: Cystatin c≤0.901 mg/L, Triglycerides≥1.487 mmol/L, Urate≥291.9 One key of the decision tree model was the classification tool of the different factors. The main sensitive factors (i.e. HDL cholesterol and smoking pack years) appeared at the beginning of the decision tree model, and at the end the main specific factors . For example, smokers superior to 9.2 smoking pack-years with low levels of HDL cholesterol, Phosphate, ALT, Urate, and Triglycerides but high levels of Albumin and Cystatin C, the probability of positive stiffness index was 82.4%. Thus, the decision tree model can present a probability based on a hierarchical classification of the different factors. To date, there are no investigation in the literature which used decision tree models for stiffness index or ASI values, and thus, it remains complicated to compare with other studies. Nevertheless, numerous investigations have observed that the eleven input variables remaining in the decision tree model have been mainly associated with arterial stiffness.The two first-order factors (i.e. HDL cholesterol and Tobacco) are well-known factor of modulation of arterial stiffness .Several investigations have shown the potential relationship between tobacco use and AS . In thisHDL-cholesterol possesses anti-CV role . SeveralMoreover, triglycerides was a major determinants for AS , 56. AugIn parallel to HDL cholesterol, Triglycerides and tobacco smoking, this study presents other biological parameters as independent predictor of increased stiffness index, such as Urate, AL, AST, Albumin, and Phosphate. The interest of this work is to present these interesting factors and their interactions on each other in a classification tool, a decision tree model. In this study, these biological parameters are mainly associated with increased stiffness index than traditional factors, such as BMI, total cholesterol, diabetes, glycemia or kidney function . This woSeveral findings have shown the association between Urate and AS in hypertensive subjects, while the mechanisms involved remains complex and not completely elucidated –62. UratFew studies have studied the association between arterial stiffness and serum ALT and AST –67. AST A negative relationship was found between serum Albumin and stiffness index, as observed in previous studies . HypoalbCystatin c is a cysteine protease inhibitor and a sensitive marker of the renal function . CystatiIn this study, in the multivariate analysis, a positive relationship was found between serum Testosterone level and stiffness index. However, in this decision model, Testosterone with low levels was present in the accuracy rules for major part of discrimination of arterial stiffness and considered as the last specific factor only for rules 1, 6 and 7. This can explain the inconsistent relation for multivariate analysis observed in the literature. Low serum Testosterone level was associated with aging-related vascular stiffness . But thiMany investigations have associated serum Phosphate with AS –80 in paThe principal strength of this investigation is the very large sample size of the population. Moreover, the use of the Pulse Trace device to measure AS on account of greater variability in ASI values relative to other available devices . The UK The study performed a decision tree model to present the different interaction between clinical and blood cutoff parameters associated with arterial stiffness, identified by a positive stiffness index.μmol/L, ALT≥22.13 U/L, AST≤32.5 U/L, Albumin≤45.92 g/L, Testosterone≥5.181 nmol/L. This work could suggest adding these biological measures in a CV assessment face to an increased AS suspicion and CV risks. Nevertheless, the results observed in this large sample of participants should be investigated in reduced and specific samples and prospective investigations to compare and validate these cutoff values. This first decision tree model remains an experimental model for stiffness index. The interest of this work was to present different classification tools for risk of high stiffness index, an index of arterial stiffness. These decision models provide accurate and useful classification tools for identifying risk associated with arterial stiffness and could be mainly developed in future programs for CV risk prevention.Ten independent factors were highlighted in the logistic multivariate analysis. The ten independent classifiers were ranked from the most sensitives: HDL cholesterol≤1.425 mmol/L, smoking pack years≥9.2pack-years, Phosphate≥1.172 mmol/L, to the most specifics: Cystatin c≤0.901 mg/L, Triglycerides≥1.487 mmol/L, Urate≥291.9 S1 Table(DOCX)Click here for additional data file.


Secondary endpoints included the best-corrected distance visual acuity (BCDVA), central corneal thickness (CCT), and graft thickness (GT). All of the evaluations were performed at follow-up appointments one, three, six and twelve months after the procedure. Results: DMEK showed a significant overall CD reduction of −7.9 ± 8.5 grayscale unit (GSU) compared to DSAEK (p < 0.001). In addition, the DMEK group showed significantly lower CDCentral,I,II,III,IV,V,VI values at follow-up appointments one, three, six and twelve months after the procedure compared to the DSAEK group (p < 0.001). BCDVA, CCT and GT were in favor of the DMEK group with a mean value of 0.39 ± 0.35 LogMar, 552.2 ± 71.1 µm and 11.03 ± 1.4 µm, respectively (p < 0.001). Conclusions: CD patterns at the graft–host interface seem to be different depending on the endothelial keratoplasty procedure. This provides specific insight into CD changes in this critical region of surgery, which may provide a better understanding of the postoperative evolution of these patients.Background: To compare corneal densitometry (CD) patterns at the graft–host interface between Descemet Membrane Endothelial Keratoplasty (DMEK) and Descemet Stripping Automated Endothelial Keratoplasty (DSAEK). Corneal densitometry is a quantitative assessment that objectively evaluates corneal clarity and optical quality by measuring the light backscatter from the cornea. Methods: Fifty-one eyes that received DMEK or DSAEK surgery for corneal endothelium dysfunction were evaluated. The primary endpoint included CD patterns at the graft–host interface, which were assessed by the Pentacam HR device at the center point of the corneal horizontal meridian (CD Endothelial keratoplasty (EK) is currently considered the main surgical therapy of corneal endothelial dysfunction, surpassing the outcomes of penetrating keratoplasty (PK) ,2. EK prCorneal densitometry, serving as an objective metric, quantitatively gauges the transparency of the cornea, which is indicative of its optical quality . This paHowever, the quality of vision is not sufficiently measured by VA and depends on other factors, such as corneal thickness, regularity, and transparency ,16,17. BThe aim of this study is to compare changes in CD patterns, specifically at the graft–host interface in DSAEK and DMEK, in addition to correlating these changes with the best-corrected distance visual acuity (BCDVA), central corneal thickness (CCT) and graft thickness (GT).This prospective, longitudinal and comparative study was carried out at the Barcelona Hospital Clinic from January 2017 to December 2019. It was approved by the institutional review board (ID: HCB/2021/1197) and adhered to the tenets of the Declaration of Helsinki. Before initiating the study, informed consent was obtained from each patient. All of the patients diagnosed with corneal endothelium dysfunction requiring EK at Barcelona Hospital Clinic were included in the study. Only cases with sufficient clinical follow-up data at 1, 3, 6 and 12 months were analyzed. The exclusion criteria included previous corneal surgeries, in addition to complex pathologies of the anterior or posterior segment, such as uncontrolled glaucoma, active vascular retinal diseases, and manifest uveitis, among others. Furthermore, eyes showing complications after EK, such as primary graft failure, immune reaction, graft rejection, and necessity for re-grafting during the course were also excluded.Regarding DSAEK surgery, a precut corneal graft  less than 150 μm thickness, stored in a specific organ culture medium  was obtained. The precut corneal graft was trephined at 8.0–8.5 mm diameter with a Barron Corneal Punch  and placed into a busin glide spatula . In addition, the corneal graft was marked on the stromal side with the letter “S” or “F” according to the surgeon’s preference. The surgical procedure followed the technique described by Busin et al.  At the eIn DMEK surgery, the corneal graft was pre-stripped at the Barcelona Eye Bank and sent to the Barcelona Hospital Clinic in a specific organ culture medium . In the theater room, the graft was trephined at 8.0–8.5 mm diameter with a Barron Corneal Punch  and then separated from the stromal bed with Troutman forceps . The DMEK procedures were performed under retrobulbar anesthetic following the “no-touch” Melles’s technique . HoweverThe CD patterns were obtained using the Pentacam HR device (Oculus Optikgeräte GmbH). This device emits a blue light beam (475 nm) as an integrated camera captures 25,000 points simultaneously and generates a series of 25 images (1003 × 520 pixels) of various corneal meridians . The sofCentral” and “CDI,II,III,IV,V,VI”, respectively, as shown in In the present study, CD patterns at the graft–host interface were evaluated in the following locations: (1) at the central point of the corneal horizontal meridian; and (2) at 6 points on the central circumference of the cornea with a total diameter of 4 mm  , which wt-test (parametric) or the Mann-Whitney U test (non-parametric). Between each group, the differences in corneal densitometry were calculated as ΔCDDMEK group − ΔCDDSAEK group. The Pearson (parametric) or the Spearman Rho correlation coefficient (non-parametric) was used to analyze the correlations between variables. In addition, stepwise multiple linear regression analysis was performed to detect the influential factors in ΔCD. The level of significance was p < 0.05 for all comparisons.Statistical analyses were performed with SPSS statistics software, version 28.0 . A sample size of 70 patients was estimated using the GRANMO calculator, version 7.12 . The estimation was based on a statistically significant paired difference at 95% confidence with 80% power of 3.35 ± 4.72 GSU in CD, as in previous studies. Continuous variables were displayed as the mean ± standard deviation (SD) with interquartile ranges [IQRs], whereas ordinal categorical variables were expressed as frequencies (n) and percentages (%). After testing for normality and homogeneity of variance, a repeated-measures ANOVA (parametric) or a Friedman test (non-parametric) was performed to compare intra-group CD. Within each group, the increment (Δ) in CD also was calculated. It was defined as the changes from the 1-month (1-mo) to the 12-month (12-mos) follow-up, or ΔCD = 12-mos − 1-mo. The inter-group CD was analyzed with the unpaired Student p < 0.001) evident in all comparative measures.Seventy-three eyes of 73 patients, 28 (50.9%) men and 45 (49.9%) women, with a mean age of 72.9 ± 9.4 (46–96) years, were enrolled in the study. Fuchs endothelial dystrophy (41.6%) and pseudophakic bullous keratopathy (31.4%) were the main causes of EK. The graft size was 7.44 ± 1.56 (7.5–8.5) mm and 8.21 ± 0.48 (7.25–8.5) mm for DSAEK and DMEK, respectively. No significant differences in demographic characteristics, ocular diseases and graft size were detected between the groups. However, 22 (30.1%) patients did not complete the study due to incomplete follow-up data. The characteristics of patients who completed the study are presented in Central is presented in Central when measured at the 1 and 12 month follow-ups (p = 0.012). In DMEK surgery, only endothelium is transplanted . This allows DMEK tissue to increase the cornea’s clarity over time. In DSAEK, the presence of the stroma reduces the possibility of a decrease in CD. Additionally, DSAEK influences the refractive outcome, whereas typically DMEK does not. Upon thorough analysis, our results indicated that there were no statistically significant differences in the changes in central corneal densitometry (ΔCD) across zones I through VI when comparing the DMEK and DSAEK groups. A comparison between the CD patterns of both groups is presented in p < 0.001). In addition, patients undergoing DMEK showed significantly lower CDcentral,I,II,III,IV,V,VI values than those undergoing DSAEK at the 1, 3, 6 and 12 month follow-ups . However, no statistically significant differences between the groups were found in the ΔCDcentral,I,II,III,IV,V,VI.Intra-group CDCentral , while ΔGT correlated significantly to ΔCDII  and ΔCDIV . However, no significant correlations were found in the DMEK group. Regarding multiple correlations in the DSAEK group, ΔCCT had the strongest association with ΔCDCentral , while ΔGT was associated with ΔCDII  and ΔCDIV . In the DMEK group, ΔCCT was also associated with ΔCDCentral , as well as with ΔCDIII , ΔCDIV  and ΔCDV .Regarding single correlations in the DSAEK group, ΔCCT displayed a significant correlation to ΔCDCentral (R2 = 0.22), suggesting a relationship between postoperative corneal thickness and transparency. Additionally, ΔGT correlated notably with densitometry in peripheral zones II and IV, reflecting the influence of graft structure on corneal clarity. Similarly, the DMEK group exhibited a consistent correlation between ΔCCT and ΔCDCentral (R2 = 0.18), with analogous correlations in zones III, IV, and V. These associations indicate a pattern in corneal responses to surgical interventions, with regional variations in clarity linked to changes in corneal and graft thickness post-DMEK. These insights help clarify how corneal structural changes post-surgery can influence optical quality.In the DSAEK group, our findings highlighted a moderate correlation between the ΔCCT and ΔCDEK has reached new frontiers for the visual rehabilitation of patients with corneal endothelial dysfunction compared to traditional PK ,33,34. DIn this study, CD patterns only improved significantly in the DMEK group after 12 months of follow-ups. In addition, the DMEK group showed significantly lower CD values compared to the DSAEK group at the 1, 3, 6 and 12 month follow-ups. Schaub et al.  reportedRegarding HOAs, Hayashi et al.  and DuggIn the postoperative period, corneal densitometry readings may be influenced by a range of inflammatory and fibrotic factors, including edema, corneal stromal fiber hyperplasia, and inflammation. These parameters, integral to the cornea’s healing and recovery processes, can affect transparency and are essential considerations when evaluating the outcomes of DMEK and DSAEK surgeries . The intThis study has some limitations that need to be addressed. The relative loss of follow-ups, as well as the small number of cases in the DSAEK group may have influenced the results. To the best of our knowledge, this is the first study to analyze CD patterns at different points of the graft–host interface in DMEK and DSAEK. Comparisons with other studies are limited because they analyze CD by regions at different depths, whereas we manually performed the CD measurements aiming at the graft–host interface. We considered that, nowadays, this was the only possible way to evaluate the graft–host interface with this device. It should be noted that this study did not evaluate the relationship between DSAEK graft thickness and corneal densitometry values, thus no data on the influence of residual stromal thickness on densitometry outcomes are available in our findings. The graft–host interface in EK seems to be important with respect to visual recovery, therefore, there is a need for new devices that automatically analyze CD at different points of the graft–host interface. Although confocal microscopy offers more precision in identifying the graft–host interface, it was not utilized in this study. Future research might benefit from employing this technique to enhance the accuracy of measurements.Overall, further studies are needed to confirm the findings reported in this study. In addition, it would be of interest to compare CD at the graft–host interface in DSAEK and DMEK with healthy a population to determine which technique achieves a better restoration of the corneal anatomy. While preoperative corneal densitometry was not assessed in this study, we acknowledge that baseline corneal clarity and high-order aberrations (HOAs) may influence postoperative densitometry patterns. Future studies could benefit from incorporating preoperative densitometry measurements to further elucidate their impact on surgical outcomes.In conclusion, CD patterns evaluated at different points of the graft–host interface were significantly lower in the DMEK group compared to the DSAEK group after 12 months of follow-ups. In addition, ΔCCT and ΔGT were significant correlated with ΔCD. At the graft–host interface, corneal stromal transparency measured by corneal Densitometry is greater in DMEK than in DSAEK. Postoperative corrected visual acuity was better in DMEK than in DSAEK and seems to relate little to corneal densitometry. However, although ΔBCDVA was significantly better in the DMEK group, it was not significantly correlated with ΔCD, which suggests an impact of other factors on the final visual outcomes. Therefore, it is important to consider multiple factors when assessing CD patterns in patients undergoing EK, as well as to analyze them in follow-ups over the long-term.


ABO incompatible (ABOi) liver transplantation (LT) was initially associated with a higher incidence of vascular, biliary, and rejection complications and a lower survival than ABO compatible (ABOc) LT. Various protocols have been proposed to manage anti-isohemagglutinin antibodies and hyperacute rejection. We present our experience with a simplified protocol using only plasmapheresis.p < 0.05 was considered significant.A retrospective review of all patients who received an ABOi LT at our institution was performed. Comparisons were made based on era  and severity of disease (status 1 vs. exception PELD at transplant). A pair-matched comparison was done to patients who received an ABOc LT. p = 0.29; PVT p = 0.37; biliary complications p = 0.15) and survival rates were similar. Patient and graft survivals were 100% in the non-status 1 ABOi patients compared to 67% (p = 0.11) and 58% (p = 0.081) respectively for patients who were transplanted as status 1.17 patients received 18 ABOi LT (3 retransplants). Median age at transplant was 7.4 months (1.1–28.9). 66.7% patients were listed as status 1. Hepatic artery thrombosis (HAT) occurred in one patient (5.6%), there were 2 cases of portal vein thrombosis (PVT) (11.1%), and 2 biliary strictures (11.1%). Patient and graft survival improved in the ABOi modern era, although not significantly. In the pair-matched comparison, complications (HAT ABO incompatible liver transplants in infants with a high PELD score have excellent outcomes. Indications for ABO incompatible transplants should be liberalized to prevent deaths on the waiting list or deterioration of children with high PELD scores. However, the rate remains the highest in small children less than 1 year of age with a range of 6.4 deaths per 100 waitlist-years (ABO incompatible (ABOi) LT is a strategy to help increase the donor pool. Although its utilization has increased in the latest OPTN report, it remains rarely utilized (5.6%). Reports from the early experience with ABOi grafts in pediatric and adult LT suggested a greater incidence of antibody-mediated (“hyperacute”) rejection, vascular thrombosis, and biliary complications –4. CircuPatient and graft survival were also noted to be lower than with ABO identical or compatible (ABOc) grafts , 6. HoweElevated anti-ABO titers were also found to be predictive of outcomes . VariousWe have been performing ABOi pediatric LT since the early years of our program, utilizing a simplified protocol solely involving PLEX after LT. Here we present our institutional ABOi management protocol as well as results with ABOi pediatric LT in the early and modern eras of our program. We hypothesize that the results are comparable to those after ABOc LT.2.2.1.A retrospective review of our institutional prospectively collected database of patients who received a LT at our institution was performed after IRB approval was obtained (IRB #2013-15357).The following data was collected: sex, indication for transplant (diagnosis), age at listing and age at transplant, height and weight at transplant, status at transplant, calculated and exception Pediatric End-stage Liver Disease (PELD) score at transplant, ABO of recipient. Transplant related data included type of graft, ABO of donor, cold ischemia time, surgery duration, intraoperative and postoperative (<24 and <72 h after LT) packed red blood cell (pRBC) transfusions, length of hospital stay. Complications that were recorded included hepatic artery thrombosis (HAT), portal vein thrombosis (PVT), bile leak, biliary stricture, biopsy proven rejection episodes, and post-transplant lymphoproliferative disease (PLTD). Vascular and biliary complications were categorized as early (≤30 days from transplant) or late (>30 days from transplant). Graft and patient status at last follow-up were noted. Cause of graft failure or patient death were recorded. Iso-hemagglutinin titers were collected pre-transplant as well as at various points post-transplant (detailed in the next section). Of note, A2 donors donating to O recipients was not considered an ABOi LT as the results of those LT differ from “true” ABOi with excellent outcomes and survival , 14.A retrospective analysis of the United Network for Organ Sharing (UNOS) data of all pediatric patients (age <18 years at transplant) who received a liver transplant alone between January 1st, 1997, and November 30th, 2020 was performed to determine the national yearly proportion of ABOi performed throughout the United States.2.2.According to United Network for Organ Sharing (UNOS) regulations  since 20Induction immunosuppression consists of methylprednisolone (10 mg/kg) given intravenously once intraoperatively . In patients with hepatorenal syndrome or acute or chronic renal insufficiency, basiliximab is also administered postoperatively on arrival in the pediatric intensive care unit (10 mg/dose for patients <35 kg and 20 mg/dose for patients ≥35 kg). A second dose (same dosage) is given on the fourth postoperative day. Intraoperatively and postoperatively, packed red blood cell transfusions (pRBC) consist of recipient ABO blood group while fresh frozen plasma (FFP) and platelet transfusions are from the donor ABO blood group due to antigens contained in FFP. Donor specific antibodies (DSA) are not routinely measured prior to LT at our institution.Our institutional fluid and anticoagulation post-transplant management has been presented in a previous publication . ImportaAnti-isohemagglutinin titers are generally measured on postoperative days 1, 3, 5, 7, and 9. Low antibody titers are considered at anything below 1:8 dilution. Five PLEX sessions are performed on postoperative days 2, 4, 6, 8, 10 using donor FFP. Patients undergo 5 PLEX sessions regardless of the variation in iso-hemagglutinin titers (even if titers are not detectable before completion of the fifth sessions). For small patients (<5 kg) who are too small either to tolerate PLEX due to volume shifts or too small for a dialysis central venous catheter, double-volume exchange transfusions is performed in lieu of PLEX.2.3.In order to assess the outcomes of ABOi LT in comparison to expected results, a pair-matching analysis was performed with ABOc transplants performed at our institution. Pair-matching was performed based on the following criteria: era of transplant ( ± 2 years from ABOi transplant date), age at transplant ( ± 2 years from age at transplant for patients who received an ABOi LT), severity of disease at transplant , and categorized indication for transplant. Categorized indications included biliary atresia (BA), cholestasis, metabolic disease, fulminant liver failure, cirrhosis, retransplantation, and other. When multiple possible matches were found for a same ABOi transplant, the match closest in age at transplant was chosen for comparison.In the United States, patients are listed for LT according to the PELD or Median End-Stage Liver Disease (MELD) scoring system (based on age younger or older than 12 years of age at the time of transplant). It reflects the 90-day patient mortality risk . The PEL2.4.t-test while categorical variables were evaluated using the χ2 test. Categorical variables with more than 2 levels were compared using multinomial logistic regression. Kaplan–Meier curves were generated to compare patient and graft survival.Continuous variables were compared using the independent p value <0.05 was considered statistically significant.Comparisons were made based on the era of our transplant program in which the transplant was performed (early era: 1997–2008 vs. modern era: 2009–2020), ABO compatibility (ABOc vs. ABOi), and on severity of disease at transplant . Statistical analysis was performed using the IBM SPSS Statistics program (version 25.0.0.0). A 3.3.1.Between August 1st, 1997, and December 31st, 2020, a total of 18 ABOi LT were performed in 17 patients. All patients and transplants were included including patients receiving a retransplantation. There was no multivisceral or multiorgan transplantation. All ABOi grafts were obtained from deceased donors.The overall proportion of ABOi LT at our institution was 4.1%. The median age at transplant was 224 days (range 31 days-28 months) and the median weight was 7.1 kg (range 3–12.8 kg). Three patients were older than 12 months old at the time of transplant and all transplanted in the early era: the first patient who received an ABOi was 22-month-old in 1999, while the 2 others were 20 and 28 months old (transplanted in 2006 and 2007). Since then, all patients have been less than 12 months old at the time of transplant.n = 7, 39%), fulminant liver failure , metabolic disease , gestational alloimmune liver disease (GALD) , and cryptogenic cirrhosis . Three ABOi were re-transplants. In 12 cases, patients were transplanted as Status 1 . The other 5 patients were transplanted with a median exception PELD of 37 (range 27–48).The indications for LT were BA (n = 8) and AB donor to A recipient (n = 5). Other transplants included B donor to O recipient (n = 2), AB donor to O recipient (n = 1), A donor to B recipient (n = 1), and AB donor to B recipient (n = 1).A whole liver transplant was performed in 5 cases, split transplant in 7 cases, and a reduced size graft in 6 cases. The portal vein was anastomosed in an end-to-end fashion in most cases (14/18), and in 4 cases, a donor iliac vein interposition graft was used. The celiac axis of the donor was most often anastomosed to the recipient's aorta (9/18). A donor iliac arterial interposition graft was used in 2 cases. The biliary anastomosis was a Roux-en-Y hepaticojejunostomy in 17 cases. There was only one duct-to-duct anastomosis. Most ABOi LT were A donor to O recipient (Early HAT occurred in one patient (5.6%) in the ABOi cohort. It occurred on postoperative day 1, could not be revascularized, and required a re-transplantation. There were 2 late HAT, one at 5 years post-transplant and one at 7 months after LT. Both grafts are functional at last follow-up (12 years and 2.9 years), as the intrahepatic arterial system was revascularized through the Roux limb arterial supply.The incidence of early portal vein thrombosis (PVT) was 5.6% (1/18). It was successfully thrombectomized on postoperative day 5. There was one late PVT occurring 5 years post-transplant in a different patient, the same patient who suffered from a late HAT. The patient has no sign or symptom of portal hypertension.There were 5 biliary complications: three early biliary leaks (16.7%), 2 requiring an anastomotic revision, while the third one was a cut surface leak. There were 2 biliary anastomotic strictures (11.1%), both requiring a percutaneous transhepatic cholangiography with balloon dilatation and stent placement. One of those 2 grafts was ultimately lost to chronic rejection and biliary complications and needed a retransplantation. This patient first suffered from an anastomotic bile leak requiring a surgical revision, which was complicated by an anastomotic stricture. There was no case of generalized ischemic cholangiopathy.Six patients suffered from acute rejection (33.3%). One child suffered from chronic rejection after her immunosuppression had to be withdrawn due to a severe adenovirus systemic infection. She was listed for retransplantation. This was not an episode of antibody mediated rejection (the C4d staining was negative on biopsy).The overall patient survival was 76.5% (13/17). Both patients who suffered from GALD died during their transplant admission : both patients had a functioning graft at the time of death. They were 4 and 5 weeks old and weighed 3.0 and 3.3kg respectively. Of note, the hemodialysis line was not used for PLEX but for dialysis due to acute kidney injury postoperatively. A third patient also died during the transplant admission: he suffered from liver failure from mitochondrial disease. He developed cardiac mitochondrial disease complications and suffered from a fatal arrythmia. He was not a heart transplant candidate. His graft was functioning at the time of death. The last patient died during re-transplantation for chronic rejection 9 months after the initial transplant from cardiac arrythmias.Only one patient who was older than 12 months at the time of transplant is still followed at our institution. She was transplanted when she was 28 months old and is still alive with good graft function 12.5 years after LT. The patient who was 20 months old died during retransplantation for chronic rejection. The patient who was 22 months old transferred care to another institution but was alive at the time of transfer 5 years posttransplant.The overall graft survival was 72.2% (13/18). Three grafts were lost to patient death and one graft was lost to chronic rejection. Lastly, one graft was lost to HAT leading to retransplantation.3.2.p = 0.29), re-transplant for HAT , and early PVT  all occurred less frequently in the ABOi group. There was no difference in patient survival between groups (The comparisons of ABOc and ABOi LT are presented in n groups . The gran groups .3.3.p = 0.067). The groups were also similar when comparing transplant related data. However, the length of the transplant surgery was statistically shorter in the modern era . There was no difference in postoperative complications. Although non-significant, the rate of early bile leak , rejection  and PTLD  were all less frequent in the modern era.Eight transplants were performed in the early era and 10 in the modern era . There wPatient and graft survivals are presented in 3.4.p = 0.004) (p = 0.037). While there was no statistical difference in the occurrence of postoperative complications, there were no vascular or biliary complications in the patients transplanted with a PELD score.Eleven patients received an ABOi graft for status 1, 1A, or 1B. All 6 patients who received an ABOi LT with a PELD score (non-status 1) were transplanted for BA. This was significantly different from the patients transplanted as status 1 where only one patient was transplanted for BA (= 0.004) . The waip = 0.11). There was a trend to a lower graft survival in the status 1 group .The 5-year patient and graft survivals were 100% in patients transplanted with a PELD score . Althoug3.5.All patients were able to complete the 5 planned sessions of PLEX stipulated in our protocol except for the 2 smaller patients who suffered from GALD. They received double-volume exchange transfusions every 48h. There were no complications from PLEX.The variation of iso-hemagglutinin titers before and after LT is presented in The same pattern was observed in the donor B in recipient O ABOi LT: the anti-A titers were high in one patient and low in the second before LT (1:1 and 1:64) and remained high (between 1:8 and 1:32) for the duration of the PLEX treatment in both patients, while the anti-B titers were high in one patient, undetectable in the second one, and both remained low for the duration of the treatment.For the donor AB in recipients A ABOi LT, the anti-B titers were low in one patient and undetectable in the other, and they remained either lower or undetectable during PLEX. The anti-A titers were mildly detectable pre-transplant and became undetectable during the duration of the treatment. A similar pattern was observed in the donor A into recipient B LT.For the donor AB into recipient O ABOi LT, AB plasma given to the patient post-transplant should not have contained either anti-A or anti-B iso-hemagglutinins. This was the first ABOi LT of our program done 25 years ago. While we cannot explain the variation of the anti-iso-hemagglutinins during the PLEX treatment or after it was completed, the patient did not suffer from any hyperacute rejection or post-LT rejection despite them being detectable.There was only one donor AB in recipient B ABOi LT. The graft was lost in the first 24h after transplant and the patient was retransplanted as a status 1A. No titers were therefore measured after transplant.4.The historical experience with ABOi LT has been associated with decreased patient and graft survival. More recent publications describe outcomes comparable to ABOc graft, including similar rates of vascular and biliary complications, rejection, and patient and graft survival , 12. OurMany strategies have been reported to help prevent the deleterious effects of circulating preformed antibodies in ABOi LT. Splenectomy is now rarely used given other medical strategies than can be utilized , 18. RitPLEX has been shown to effectively reduce anti-donor iso-hemagglutinin levels . AlthougIn some studies, direct portal vein or hepatic artery infusions have been utilized to deliver agents directly to the vascular endothelium of the ABOi graft, a technique believed to prevent AMR more successfully than systemic delivery , 25. WhiA recent multicenter European collaborative report described the outcomes after ABOi and presented the various perioperative medical management strategies for ABOi LT . There wIn our experience, all ABOi grafts were obtained from deceased donors. However, in countries where access to deceased donors is less readily available such as Japan and Saudi Arabia, living donor ABOi have been successfully performed , 27. ThiOur study showed a decrease in donor-specific iso-hemagglutinin after ABOi LT, while third party antibodies continued to be detected. The latter can be explained by the administration of donor specific FFP which contains non-donor directed circulating iso-hemagglutinins. In addition, we have unpublished evidence that the titers previously reported as low even in the absence of plasmapheresis may be due to the donor specific anti iso-hemagglutinins being adsorbed on to the donor liver endothelium. Liver biopsies stained for anti-endothelial antibodies to the vascular endothelium may be positive. This negates the reassuring absence of a detectable DSA in the recipient serum reported by others as evidence that antibody monitoring may serve as a guide to the need for PLEX. Similar to how the liver exerts a protective effect on kidney transplants from the same donor with a positive cross match in regard to anti HLA antibodies by absorbing the antibodies, the same effect may be at work in the case of anti-hemagglutinin antibodies. However, to prove this latter hypothesis would require repeated liver biopsies and specific staining for DSA, which we have not performed in the setting of this study.There is evidence that over the long term of several weeks or months after LT the graft reduces the expression of donor ABO blood group on the endothelium and assumes the phenotype of the recipient blood group . Thus, tIn our protocol, all patients receive post LT PLEX regardless of their pre-LT donor-specific titers. PLEX is efficient at reducing anti-A and anti-B titers. A recently published study recommended an aggressive management for patients with titers >1:16  while not administering any treatment to patients with lower titers . The 1:1Most children being listed for an ABOi LT are acutely sick and are coagulopathic before LT, and often receive blood products including FFP that will contain iso-hemagglutinins against non-self-antigens. This passive administration of potential anti-donor antibodies contributes to the higher titers observed in some of our patients' pre-LT and is not due to inherent antibody production by the sick infant.Our protocol changes the post LT fluid replacement to donor specific FFP that then contains no antibodies that could potentially damage the graft, and explains the higher titers of third party, non-donor directed iso-hemagglutinin antibodies.Our results support the favorable outcomes observed after ABOi LT in children less than one year of age. Infants less than one year of age have an immature complement system  and do nWhile the outcomes after ABOc and ABOi LT were similar in our series, there was a significantly lower patient and graft survival for ABOi LT in children who were transplanted as status 1 compared to those transplanted with a PELD score. It has previously been shown that worst outcomes observed after ABOi were attributable to the patient's medical urgency at the time of LT rather than to the incompatibility , 31. UndSome groups have reported excellent patient and graft survival after ABOi, as high as 100% , 11, 12.The authors recognize limitations to their study. It is a single center retrospective study with a small number of patients. However, most reports on pediatric ABOi LT are single-center study with a number of patients similar to ours. Also, the study spans over 25 years, and while the ABOi management protocol did not change, the immunosuppression management changed greatly  and this might have affected the rate of post-LT rejection rates.In conclusion, the outcomes after ABO incompatible pediatric liver transplant have improved and are now comparable to ABO compatible transplants. ABO incompatible grafts should therefore be increasingly utilized by pediatric transplant programs to help increase the donor pool and reduce the waitlist mortality in children less than 12 months of age. Crossing blood groups in pediatric liver transplantation remains reserved for the sickest infants, which may affect post transplant outcomes. National policies need to be modified to allow small children to be eligible for an ABO incompatible transplant with a lower natural PELD score.


Subscapularis integrity is correlated with function following shoulder arthroplasty. Failure of healing, particularly following anatomic total shoulder arthroplasty, is associated with poor outcomes and the need for revision. Graft augmentation has been used to increase healing following rotator cuff repair but has not been commonly advocated for augmenting the subscapularis following shoulder arthroplasty. The long head biceps tendon is typically tenodesed and discarded during shoulder arthroplasty. Rather than discarding the tendon, the tendon may be compressed and applied to the subscapularis as a biologic scaffold to potentially improve subscapularis healing following shoulder arthroplasty. The presence of fraying or synovitis of the LHBT encountered intraoperatively does not necessarily exclude the patient for biological augmentation.The steps of the procedure are displayed in Prior to performing the subscapularis repair, the compressed biceps graft is prepared on the back table. If the level of the proximal resection was flush with the labrum, the proximal 5 mm of the graft is discarded as this segment tends to be more cartilaginous and not compress as well. A 27 mm segment from the proximal aspect is then obtained . The tenIn the setting of a tenotomy approach, a side-to-side repair is performed in the standard fashion. The graft is then held over the tenotomy repair site with the biceps graft aligned from superior to inferior. This orientation makes it so that the sutures will pass perpendicular to the normal orientation of the biceps tendon fibers. The 4 corners of the graft are sutured to the native tendon using 4 independent #2 sutures placed in a figure-of-eight configuration.,Most commonly, we utilize a subscapularis peel or lesser tuberosity osteotomy approach and repair the tendon with 2 mm suture tapes  . The fulThe compressed biceps autograft augmentation technique provides a technique for potentially improving subscapularis healing following shoulder arthroplasty. The LHBT graft source is low cost, present in most shoulder arthroplasties, and has demonstrated cell viability following compression.,Subscapularis failure following TSA is a recognized cause of decreased function and implant failure.,,,P = .0058). Thus, the lack of clarity regarding subscapularis repair following RSA may be partially due to the inherently low healing rates. Low healing rates in the setting of RSA can be attributed to distalization of the subscapularis tendon as well as the poor native biologic environment in the case of rotator cuff arthropathy. In the latter case, there may be an opportunity to improve healing and subsequent function with biologic augmentation.The importance of subscapularis repair and healing following RSA has been a subject of controversy. Some studies have reported minimal to no difference in patient function whether or not the subscapularis was repaired following RSA.The LHBT is a promising graft source for augmentation of subscapularis repair for several reasons. First, the graft source is low cost, making use of a segment of the tendon that is routinely discarded. Second, there is no donor site morbidity. Third, the graft appears to retain biologic viability even after compression. Colbath et al analyzed the biological and tensile properties of a compressed LHBT graft and demonstrated that 39% of tenocytes were viable.Further studies are clearly required to investigate this technique. First, a biomechanical investigation would be valuable to determine if the augmentation improves load to failure or minimizes displacement. Most importantly, a clinical study evaluating healing would be valuable. However, as opposed to allografts which require substantially increased cost, there appears to be very little downside to the current technique.During shoulder arthroplasty, the proximal segment of the long head of the biceps tendon is routinely discarded. Rather than discarding the tendon, we have described a technique for compressing the biceps into a flat graft for autologous biologic augmentation of subscapularis repair following shoulder arthroplasty.Funding: No funding was disclosed by the authors.Conflicts of interest: Dr. Denard is a consultant for and receives royalties from Arthrex, Inc. Dr. Dines is a consultant for and receives royalties from Arthrex, Inc. Dr. Tokish is a consultant and receives royalties from Arthrex. He has recently served on the Scientific Advisory Board for Depuy Mitek, and is an Associate Editor for the Journal of Shoulder and Elbow Surgery. The other authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.


The aim of this study was to determine the ability to improve the capacity of cold swelling and cold-water solubility of rice starch by ultrasonic-assisted alcohol-alkaline and alcohol-alkaline methods. To achieve this, ultrasound powers (U) were varied  under the granular cold-water swelling starch (GCWSS) preparation . The effects of these methods on morphological, pasting properties, amylose content, ratio of 1047/1022 spectra by FTIR, turbidity, freeze–thaw stability, and gel texture were also studied and compared. The results showed that the surface of GCWSS granules presented a honeycomb especially GCWSS + U treatments exhibited more porous on the surface of starch granules. The cold swelling power and solubility of GCWSS + U samples were increased which confirmed by reducing ratio of ordered structure to amorphous structure of starch, and turbidity was also decreased. Moreover, pasting temperature, breakdown, final viscosity, and setback decreased while peak viscosity increased as measured using a Rapid Visco Analyzer. The freeze–thaw stability of GCWSS + U was more resistant to syneresis than GCWSS under repeated freeze–thaw cycles. The reduction of gel hardness and springiness was observed using Texture Analyzer. These changes were enhanced with increasing ultrasound powers. Thus, the results indicate that the different ultrasound-assisted alcohol-alkaline treatments for preparing GCWSS show an effective use in the preparation of GCWSS with improved cold-water swelling and reduced retrogradation of rice starch. Therefore, this starch can rapidly and largely dissolve in cold because of its high-water absorption and swelling without heating assistance 22.1Commercial rice starch was purchased from Thai Flour Industry Co., Ltd. . Protein, fat, and amylose content of native rice starch was 1.31%, 0.01%, and 19.14%, respectively. Ethanol (99% purity), hydrochloric acid (HCl), and sodium hydroxide (NaOH) were purchased from RCI Lapscan, Ireland.2.2Granular-cold water swelling rice starches were prepared by the method of Zhu, Liu 2.3The starch sample was sprayed on an aluminum stub with double-adhesive tape. The sample stage was sputter-coated with gold. After that, the sample was observed using FEI Quanta scanning electron microscope  under a vacuum at the accelerating voltage of 20 kV.2.42 and 2% KI, w/v). The mixture was quickly mixed and left in the dark for 20 min. The absorbance at 620 nm was recorded to calculate the apparent amylose concentration. By using a standard curve made using potato amylose (Sigma-Aldrich), the recorded data were converted to percent of amylose.The amylose content of rice starch and GCWSS samples was determined by an iodine colorimetric method described by Fang, Huang 2.5The cold-water absorption and cold-water solubility of GCWS rice starch were measured according to the method of Hedayati, Shahidi 2.6−1 range. They computed the intensity ratio  at 1047 and 1022 cm−1 , which as known as ratio of ordered structure starch to amorphous structure starch Fourier transform infrared spectroscopy (FTIR)  was used to measure the starch samples' FTIR pattern. OPUS 8.0 software was used to baseline correct and normalize the spectra, which were collected in the 4000–400 cm2.7The pasting properties of starches were measured using Rapid Visco Analyzer (RVA)  following the method of Approved Method 61–02 . 3 g of Rice starch was weighed and added 25 g of distilled water into an RVA canister. The suspension was heated to 50℃ with stirred at 160 rpm for 1 min, heated to 95℃ at the rate of 5℃/min for 3.42 min, held at 95℃ for 2.3 min, cooled to 50 °C, and finally held at 50℃ for 3 min. The pasting profiles were recorded including pasting temperature (PT), pasting viscosity (PV), breakdown (BD), and final viscosity (FV).2.8The analysis of turbidity of starches was a modified version of Ye, Luo 2.9The method of freeze–thaw stability was determined according to the method described by Hedayati, Shahidi Water syneresis (%) =  × 100.2.10After pasting analysis, the starch paste in a container was sealed with paraffin film and kept for 24 h at 4℃. The gel was then analyzed texture profile using Texture Analyzer (TA-XT2i) following the method of Wu, Han 2.11All the samples were carried out in at least three replicates and the data water analyzed using SPSS for window version 21 . Analysis of variance (ANOVA) was performed, and Duncan’s multiple range test was used for comparison of means at a significance level of 0.05.33.1In the process of changing rice starch swelling and solubility characteristics by alcoholic-alkaline treatment with/without aid of ultrasonic waves, the appearance structure of starch granules could change. The scanning electron micrographs (SEM), one of the structure analysis methods, shows the surface difference between the native rice starch and GCWSS granules under different treatment . SEM mic3.2The amylose content of native rice starch and GCWSS samples are shown in 3.3p ≤ 0.05) at a room temperature. This result could be due to the function of the alkaline producing starch molecules negatively charged, which led the starch granular swell by the forces of electrostatic repulsion mechanism. As swelling develops, double helical regions become single helical regions, and the crystalline structure is disrupted, resulting in amylose molecules being leached out of starch molecules; thus, the solubility value of GCWSS increased. Meanwhile, when comparing GWCSS samples, samples with ultrasonic treatment showed remarkably higher swelling and water solubility at room temperature than untreated samples. Specifically, the water swelling of the GWCSS + U samples was higher about 0.09–20.15% compared with the GWCSS sample when the ultrasonic amplitude power increased from 30% to 100%. Besides that, the cold-water solubility capacity also enhanced significantly by 21.4–95.2% when applying ultrasound waves combined with alcoholic-alkaline treatment. This result may be due to the influence of granular surface change as previously analyzed results by SEM. The mechanical jet impact of ultrasonic waves that create cavitation collapse of bubbles on the surface leading to cracks and fissures surface that increase the permeability of water into the starch granules Water swelling and water solubility are indicators of the interactions between the starch molecule chains in the crystalline and amorphous regions with water molecules. Cold-water swelling and cold-water solubility of the native rice starch and GCWSS samples are also shown in 3.4−1 (C = C stretching) and 1022 cm−1 (C = O stretching), known as the infrared index R1047/1022 , serves as an indicator of the amount of ordered starch compared to amorphous starch −1 peak was observed, particularly in GCWSS samples treated with ultrasound power ranging from 70% to 100%. This shift can be attributed to the disruption of intra-molecular hydrogen bonds in rice starch caused by ultrasound, leading to changes in spectral patterns and increased starch solubility 3.5p ≤ 0.05) in pasting temperature, peak viscosity, breakdown, and final viscosity. GCWSS sample showed a significantly lower pasting temperature, pasting viscosity, breakdown, and final viscosity, while exhibited a higher setback value as compared to the native rice starch. These results could be due to the destruction of crystalline structure during alcoholic-alkaline treatment, resulting in decreased gelatinization temperature and pasting viscosity of starch paste The pasting properties of native rice starch and GCWSS rice starch samples are summarized in 3.6Turbidity measurement is another approach used to evaluate starch retrogradation 3.7During freezing, water molecules in starch gels form ice crystals, and starch molecules aggregate. When thawed, the starch gels are separated into water and starch-rich phases, this phenomenon is defined the syneresis. Repeating the freeze–thaw cycles enforce the phase separation and ice growth 3.84The solubility and swelling of rice starch is improved when treated with alcohol-alkali treatment and ultrasonic-assisted alcohol-alkali treatment, especially ultrasonic-assisted alcohol-alkali treatment for superior ability. Furthermore, during GWSS treatment brought about changes in the pasting properties, turbidity, cold-water swelling, cold-water solubility, gel texture properties and syneresis value in rice starch. GCWSS + U presented a softer gel and produced clearer gel than GCWSS rice starch. Increasing ultrasound power level enhanced a reduction of syneresis of GCWSS + U. GCWSS + 70 %U and GCWSS + 100 %U showed an increase in the syneresis values occurred at the first freeze–thaw cycle and remained constant after second freeze–thaw cycle. In summary, ultrasound assisted alcohol-alkaline treatment could be used for preparation to produce granular-cold water swelling starch and could be use in frozen products as it had less syneresis and retrogradation in further.Kannika Kunyanee: Writing – original draft, Conceptualization, Visualization, Formal analysis, Data curation, Supervision. Kanyarak Phadtaisong: . Jutarat Na Chiangmai: Formal analysis. Natch Parittapongsachai: . Tai Van Ngo: Writing – review & editing. Naphatrapi Luangsakul: Writing – review & editing. Sirada Sungsinchai: Writing – review & editing, Supervision.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Correction to: Journal of Interventional Cardiac Electrophysiology10.1007/s10840-023-01559-zFigure The original article has been corrected.


The Kruskal–Wallis tests revealed a statistically significant difference  in the mean marginal gaps between different materials. (4) Conclusions: The proposed digital workflow can be a viable alternative for fixed prosthetic rehabilitations. The best performance in terms of marginal gap was achieved by zirconia crowns, but all three materials demonstrate marginal closure below the clinically accepted threshold value (120 µm). Clinical significance: although significant differences were reported, the investigated CAD/CAM materials showed clinically acceptable marginal gaps.(1) Background: The objective of this in vitro study is to evaluate the marginal accuracy of crowns created by CAD/CAM. (2) Methods: A customized chrome-cobalt (Cr-Co) implant abutment simulating a maxillary right first molar was fixed in a hemi-maxillary stone model and scanned. In total, 27 crowns were fabricated, including 9 lithium disilicate crowns, 9 composite crowns, and 9 zirconia crowns. The measurements were determined by scanning electron microscopy. Descriptive analysis was performed using the mean and standard deviation, while the Kruskal–Wallis test was performed to determine whether the marginal discrepancies were significantly different between each group ( There are four specific attributes that a dental restoration must possess in order to be considered successful, which are: marginal adaptation, biocompatibility, aesthetics, and mechanical strength . ResearcMarginal fit is an important factor for the success of tooth restoration. Marginal discrepancies in a dental restoration can have several negative consequences, such as increased plaque accumulation, altered microflora distribution, and a higher risk of caries in the abutment teeth in the case of natural teeth ,8,9. TheMcLean and Von Fraunhofer, in an in vivo study on 1000 restorations with 5-year follow-ups, concluded that the degree of acceptable marginal discrepancy is up to 120 microns . Since mThe dental laboratory prepared a plaster model, which was a right hemi-maxilla, in order to simulate the situation of a dental-supported single crown in position #16.A customized cobalt-chrome (Cr-Co) abutment was manufactured according to the STL file generated by a 3D CAD modeling software . The abutment provided a diameter of 1 cm, height of 1 cm, a taper of 3°, and a 2-mm-deep 360° chamfer as a marginal design. a The finA scan of the hemi-model was created with Cerec Primescan  and ended with the exportation of data in Standard Tessellation Language (STL) format. After scanning and creating the model, the finish line was marked, and the crown was designed on a Cerec Primescan touch desktop.  The coreBefore starting the coping production, a test coping was produced in order to evaluate the right fit according to abutment geometry and prosthetic materials. Once the ideal fit was identified, the same parameters were established and kept constant throughout the entire process. The design was evaluated for proper contacts and contours, and the crowns were fabricated in succession with the Cerec inLab MC XL  milling machine and sintered (for G1 and G2) with the Cerec SpeedFire  following the manufacturer’s recommendations. The time for each crown production was recorded.n = 9) (-n = 9): zirconia (Katana Zirconia STML);Group 1 (-n = 9): lithium disilicate (Cerec Tessera);Group 2 (-n = 9): composite (Katana Avencia Block).Group 3  :-Group 1According to the restoration’s material and the manufacturer’s indications, different burs were used for the milling process: Shaper 25 RZ and Finisher 10 burs were used for zirconia, while Cylinder Pointed Bur 12S  and Step Bur 12S  were used for lithium disilicate and composite. Before beginning the scanning electron microscope (SEM) investigation, a fit check was performed for all the specimens. A sample size of 15,000 points with a tolerance of 0.001 mm was used in the 3D analysis software  to check differences among the produced crowns. Then, each crown was positioned on the abutment and kept in place by a hand-crafted elastic metal spring capable of retaining the crown in the ideal position and at the maximum depth of fit. No material was inserted at the interface abutment-restoration.Observations were made with a PhenomPro X SEM  at Metalcoating SRL . By positioning the stump on specially designed metal frames, it was possible to keep the various specimens in the same position throughout the various scans with a constant inclination of 25° to the perpendicular electron beam. This ensured that the specimen’s inclination and, consequently, the angle of incidence of the scanning electron beam were always the same. Photomicrographs  were obtThe marginal gap at the restoration-abutment interface was measured at the vestibular (V), palatal (P), mesial (M), and distal (D) aspects. For each side, the point at minimum radial distance between the circumference and the corresponding aspect was identified, resulting in the V, P, M, and D points . Then, aDescriptive statistics were presented as means and standard deviations. The Kruskal–Wallis and the Dunn tests with the Bonferroni correction were used to analyze differences among groups. The statistical analyses were performed using the software package .The SEM analysis of marginal gap performed on 324 points (12 for each coping) showed a total mean value of 21.45 ± 12.58 μm for zirconia, 62.28 ± 51.8 μm for disilicate, and 44.7 ± 24.96 μm for composite crowns, with statistically significant differences between the three groups . The samp < 0.0001) and group 3 (p < 0.0001). No other differences were statistically significant.When considering all the measurements, pairwise comparisons using Dunn’s test indicated that group 1 scores were observed to be significantly lower than those of group 2 (Results varied when the gap’s location was taken into account .p < 0.0001) and group 3 (p < 0.0001), and there was a statistically significant difference between group 2 and 3 (p = 0.0232). In terms of vestibular gaps, group 1 scores were significantly lower than those of group 2 (p = 0.0014) and group 2 (p < 0.0001).Regarding the palatal gap, group 3 scores were significantly different from those of group 1 (p < 0.0001) and group 1 vs. group 3 (p = 0.0001), while in the distal aspect, it was only significant for group 1 vs. group 2 (p = 0.0047).At mesial aspect, the post-hoc test was significant for group 1 vs. group 2 , with an average of 16 min per crown. The material with the longest production time was zirconia .An increasing demand for esthetic dental restorations has led to the popularity of ceramic restoration systems. Contemporary esthetic materials for indirect restorations are widely used in dentistry as they meet the functional and esthetic demands of both the anterior and posterior regions of the mouth. The long-term success of indirect restorations relies heavily on the marginal and internal fit. When there is a misfit, plaque can accumulate, potentially causing caries or periodontal diseases, especially in restorations with subgingival margins . MoreoveThe present study examined the marginal fit of three different CAD/CAM materials that are widely clinically used. Since significant differences were observed among the investigated materials, the null hypothesis has to be rejected. It was therefore, concluded that the performance of a specific CAD/CAM system, in relation to marginal adaptation, is influenced by the type of restorative material. Marginal adaptation is a very important clinical parameter because a wide marginal gap can determine postoperative sensitivity, secondary decay, discoloration of the margins, an unesthetic appearance, and mechanical failure. A recent literature review reported that the absence of consensus regarding the precision of fit of different crown materials should be related to differences in experimental protocols .The final fit of the restoration can, in fact, be affected by several factors. Among them, the design of the finishing line is one of the most investigated factors, with some studies reporting no significant differences between horizontal and vertical finish lines ,33,34,35In the present in vitro investigation, although significantly different, all the tested crown materials showed clinically acceptable values of marginal discrepancy. The size of the marginal gap of all milled crowns in the present study was in fact lower than 120 μm, which has been identified as the threshold value for a clinically acceptable marginal gap allowing to achieve a good long-term success of prosthetic crowns ,45. ThesParticularly, the zirconia crowns showed the best precision of fit at the preparation margins (21.45 ± 12.58 μm). This could be explained by several factors, such as the fact that dental CAD/CAM systems were developed for processing polycrystalline materials, which led to the creation of more accurate results ,47,48,49In the present study, we focused on the marginal gap as it is considered a reliable analysis for crown adaptation assessment ,50. WhilThis study investigated three types of materials: zirconia, composites, and lithium disilicate.Each of these materials has its own unique properties and characteristics, which make them suitable for different clinical situations.Zirconia is a type of ceramic material that is known for its strength and durability. It is highly resistant to wear and fracture, making it an excellent choice for restorations in areas of the mouth that are subject to high stress, such as molars. Additionally, zirconia is biocompatible, which means that it is unlikely to cause an adverse reaction in the body. Zirconia is also highly aesthetic and can be matched to the color of natural teeth. Composite, on the other hand, is a tooth-colored resin material that is used for dental restorations. It is a popular choice for fillings and bonding procedures because it can be easily molded and shaped to match the contours of the teeth. Composite is also highly esthetic and can be color-matched to the surrounding teeth for a natural-looking result. However, it is not as strong as zirconia and may not be suitable for restorations in areas of the mouth that are subject to high stress. Lithium disilicate is another type of ceramic material that is used for dental restorations. It is known for its strength and esthetic qualities, making it a popular choice for crowns, veneers, and other types of restorations. Lithium disilicate is also biocompatible and can be matched to the color of natural teeth. However, similar to composite, it may not be as strong as zirconia and may not be suitable for restorations in areas of the mouth that are subject to high stress.Of the monolithic CAD/CAM materials that have been recently introduced for cuspal coverage, indirect restorations on severely damaged teeth, zirconia has undergone significant advancements. High-translucency zirconia has emerged as a promising replacement for tetragonal zirconia, particularly for monolithic single-tooth restorations. By introducing a variable amount of cubic phase, which is optically isotropic, the translucency of the material has been enhanced. However, this comes at the cost of strength and toughness due to the lack of transformation toughening and the coarser microstructure . InitialThe use of CAD/CAM composite blocks, also known as nano-hybrid ceramic, resin nano-ceramic, resin ceramic, nanohybrid restorative materials, resin-based composite blocks, or hybrid composites, has become increasingly popular due to their superior quality compared to conventional composite materials used in conventional analogic dental procedures for both direct and indirect restorations . This isIn our study, Katana Avencia, a composite block was analyzed. This study analyzed marginal fit, nevertheless, it has to be reminded that mechanical properties shall be always considered, being CCBs affected by monomer compositions, especially if specific types of monomers are contained  ,57,58,59IPS e.max  was introduced in 2005 and can be utilized through two techniques: the lost wax hot press method (IPS e.max Press) or the digital CAD/CAM approach (IPS e.max CAD) ,61. IPS Several marginal gaps for CAD/CAM lithium disilicate were in fact reported in the literature: 33.30 μm , 84 μm ; the latDifferent measuring methods of marginal discrepancies have been described in the literature, including the direct-view technique by using scanning electron microscopy ,71, or oIn our study, the measurement of the marginal gap was performed using the direct view technique with a SEM. In order to ensure accuracy and repeatability of the measurements, custom support frames were positioned at a constant angle of 25° to the incident electron beam. Moreover, precise positioning of the specimens was also aided by the reproducible and repeatable anatomy of the crowns, since they were all milled from the same initial design.Furthermore, the selection of measurement points is another crucial point. Studies have recommended that at least 10 points be randomly selected to measure the adaptation of the restoration and that measurements should be performed throughout the restoration.  In this It has to be also highlighted the importance of relating the findings of this article to other mechanical tests, in particular the ones related to wear. The wear mechanism in dental materials can be categorized into two types: two-body and three-body wear. Two-body wear involves the contact between two surfaces, where the opposing surfaces rub against each other. This type of wear is commonly seen in materials such as ceramics, where a hard surface is in direct contact with another hard surface. In two-body wear, the wear rate is typically lower, and the wear patterns are predictable. The wear mechanism can be influenced by factors such as load, surface roughness, and material properties ,88.On the other hand, three-body wear occurs when particles or debris become trapped between the two surfaces in contact. The debris acts as an abrasive and leads to faster wear rates and more unpredictable wear patterns. Three-body wear is common in materials such as composites and dental amalgam, where particles can be released during chewing or abrasive forces. The wear rate can be influenced by factors such as particle size and shape, volume fraction of particles, and the properties of the matrix material. Therefore, an understanding of the wear mechanisms in dental materials is crucial for the development of durable and long-lasting restorations ,88.Relating to the novelty of the current study, we outlined the better marginal fit of zirconia frameworks. A marginal seal is the interface between the crown and the tooth that is created to prevent bacteria and debris from entering the space between the crown and the tooth. This seal is essential for the long-term success of a dental restoration. Zirconia is a ceramic material that has become popular for use in dental crowns due to its superior strength and aesthetics. One of the key advantages of zirconia crowns over other ceramic materials is their ability to create a better marginal seal.Zirconia crowns are known for their excellent fit and accuracy , which iFurthermore, zirconia crowns have a high resistance to wear and fracture, which means that they are less likely to break down over time, thereby maintaining the marginal seal for a longer period . In contThis study has some limitations related to study design. As an in vitro experiment, this could not include in vivo factors, such as patient cooperation or contamination with biologic fluid during the scanning process. It must indeed be emphasized that while fit is a critical factor in the clinical success of complete crowns, it is only one of several contributing factors. Another limitation is that only one scanner system and one milling machine was used. Further study and clinical applications should be performed involving cyclic fatigue  in the eTaking into account the limitations of the present in vitro investigation, the researchers were able to draw two important conclusions. Firstly, all the tested crown types showed marginal gaps that fell within the acceptable clinical range. This is a significant finding, as marginal adaptation is essential for preventing bacterial invasion and decay of the underlying tooth structure. Secondly, the study found that zirconia crowns exhibited better marginal adaptation than lithium disilicate and composite crowns. However, it is important to note that the results of this study should be interpreted with caution, given the in vitro setting and the need for further clinical trials to validate the findings. Additionally, the study was conducted under controlled laboratory conditions and may not necessarily reflect clinical reality. Therefore, these findings should be taken as a starting point for further research in this area.