Small quantities of lipids accumulate in the white rice grains. These are grouped into non-starch lipid and starch lipid fractions that affect starch properties through association with starch. Lysophosphatidylcholine (LPC) and lysophosphatidylethanolamine (LPE) are two major lipid classes in the two fractions. Using high-oleic rice grains, we investigated the fatty-acid composition in flour and starch by LC-MS and evaluated its impact on starch properties. In the wild-type grain, nearly 50% of fatty acids in LPC and LPE were palmitic acid (C16:0), over 20% linoleic acid (C18:2) and less than 10% oleic acid (C18:1). In the high-oleic rice grain, C18:1 increased at the expense of C18:2 and C16:0. The compositional changes in starch lipids suggest that LPC and LPE are transported to an amyloplast with an origin from endoplasmic reticulum-derived PC and PE during endosperm development. The high-dissociation temperature of the amylose-lipid complex (ALC) and restricted starch swelling power in the high-oleic rice starch indicates that the stability of the ALC involving C18:1 is higher than that of C18:2 and C16:0. This study provides insight into the lipid deposition and starch properties of rice grains with optimized fatty-acid composition. Lipids comprise 1–4% of whole grain rice and most of it is concentrated in the bran and embryo while a small amount exists in the starch-rich endosperm. Total lipids extracted from rice bran consist of 84.9–86.0% triacylglycerols (TAGs), 6.5–6.7% phospholipids (PLs) and 4.2–4.6% free fatty acids (FFAs) . Non-staAlthough lipids are minor components of the rice endosperm, they play an important role in starch quality through their combination and interaction with the major grain component, starch, which is synthesized mainly through glucose polymerizing and forms granules in the amyloplast of the endosperm cells during seed development. The lipid content of white rice grain is generally correlated with the amylose content of starch, especially the starch lipids that are believed to be physically associated with the amylose molecules . Amylosew/w) lipid can induce ALC formation, and a 10% lipid can theoretically complex with all the amylose [The formation of ALCs restricts the swelling of starch granules, increases gelatinization temperature, reduces starch hydrolysis and significantly affects starch properties and digestibility in both food and animal feed ,9,10. Th amylose . The cry amylose . The oth amylose ,14.Through intermolecular interactions, LPLs make major contributions to the functionality of ALCs. In this context, much work has been done on the lipids of cereal grain endosperms ,15,16,17sn-2 acyltransferases, a C16 fatty acid at the sn-2 position is a signature for chloroplastidial lipids, while the ER-derived phospholipids typically carry a C18 fatty acid at the sn-2 position. Eukaryotic phospholipid PC is synthesised in the ER but is also present in the outer chloroplast envelope [Plant fatty acid de novo biosynthesis occurs in the plastid. The synthesised fatty acids are incorporated into plastidial lipids including galactolipids and phospholipids via the prokaryotic pathway. In addition, de novo synthesized fatty acids can enter extraplastidial membrane lipids including phosphatidylcholine (PC) via an acyl editing process or by the conversion of diacylglycerol (DAG), which is synthesised in the endoplasmic reticulum (ER) to PC. DAG backbones are the precursors both for plastid lipid synthesis and eukaryotic phospholipids PC and phosphatidylethanolamine (PE) . Due to envelope .sn-2 position is catalysed by fatty acid desaturase 2 (FAD2). We have previously reported on the genetic down-regulation of the major FAD2 gene (FAD2-1) in the seed via RNA interference (RNAi) [FAD2-1 down-regulation (DRFAD2) were used to investigate starch lipids deposition in the endosperm and characterise starch functional properties.Further desaturation from C18:1 to C18:2 at the e (RNAi) . The C18e (RNAi) . Acyl-Coe (RNAi) ,4,5, in FAD2-1 RNAi line and its background variety O. sativa cv. Nipponbare to create a population with a clear genetic background [1 seed of the FAD2-1 RNAi line backcross was grown to develop the F2 population for DNA marker-assisted selection up to the F4 generation. All plants were grown in the phytotron at CSIRO Black Mountain Scientific Innovation Park  at 23–29 °C under natural daylight. Leaf tissue was collected from each plant from generations F1 to F4 for quick DNA extraction [FAD2-1 RNAi constructs by PCR as reported previously [For the study, a cross was made between the previously developed ckground . The F1 traction . DNA mareviously . Mature 2 line carrying the RNAi construct for total fatty acid (TFA) profiling. Each grain was loaded into a 2 mL Eppendorf tube, and ground into flour using a 3M ESPE CapMax™ homogenizer . About 4 mg of flour was weighed for total lipid extraction and fatty acid methyl ester (FAME) preparation following the published procedure with modification as described by Zaplin et al. [FAD2-1 RNAi (DRFAD2) segregants in F2 progeny and three wild-type FAD2-1 (WTFAD2) segregants were selected as the control for the following analysis. Phenotyping by single grain TFA profiling was repeated using 12 grains of the selected lines to confirm genetic stability until F4.For screening purposes, 12 brown rice grains were selected from each Fn et al. , and anag for 2 min. The pellet was washed with water and resuspended in a 50 mM phosphate buffer (pH 7.5) containing 50 µg/mL proteinase K. After incubation for 2 h, the obtained starch extract was rewashed with water three times. The starch pellet collected by centrifugation was freeze-dried overnight.Brown rice grains of 150–200 mg of each selected line were loaded into a homemade polisher fitted with an abrasive metal brush and sandpaper. Rice bran was removed from the brown rice grains by polishing for 1 min to produce white rice grains. These were then ground in a capsule with ball bearings using a 3M ESPE CapMix™ capsule mixer  to produce white rice flour, of which approximately 500 mg of grains from each line were washed with 0.005% NaOH and filtered through 0.5 mm nylon sieves followed by centrifugation at 10,000× v/v; 0.5 mL) three times sequentially. The liquid extracts were combined and dried under a nitrogen stream. The dried extracts were dissolved in 0.8 mL of chloroform/methanol  and the non-starch LPLs were quantified by LC−MS according to Liu et al. [m/z 524, eluted at 6.4 min) and LPE 18:0  observed in the samples along with the previous study [v/v) at 100 °C for 2 h. The extracts thus obtained were subjected to the same LC–MS method to determine starch LPLs.Total lipids were extracted from white rice grain and LPLs were determined in duplicates for all three biological replicates by a Liquid Chromatography−Mass Spectrometry (LC−MS) method described by Liu et al. . Brieflyu et al. . Includeus study . Starch White rice flour was used for a total starch content (TSC) determination using a Megazyme total starch analysis kit . Samples were duplicated and fitted to a 96-well microplate following the manufacturer’s procedure (AACC Method 76.13). The amylose content was determined by iodometric estimation . ProteinRice starch samples of 45 mg were homogenized in 90 mL water in duplicate and used to determine the starch thermal profiles of each line using a Differential Scanning Calorimeter . The procedure was conducted according to the published method and data were analyzed using the manufacturer software supplied with the instrument . About 2The starch samples were debranched with isoamylase . The sample preparation followed the published method with modifications . The molt-test and Analysis of Variance of Genstat version 9 at the level of p < 0.05 and p < 0.01 for statistical significance.Statistical analyses were performed using FAD2-1 RNAi backcross population progenies was determined by PCR markers and single-grain TFA profiling. Among 22 F2 progeny, four transgenic null sergeants  were identified and thus considered as a homozygous WTFAD2 genotype. The other 18 progeny carrying the RNAi construct were screened further by single-grain TFA profiling. The TFA composition of individual seeds of D5-1, D5-5, D5-7 and D5-8 consistently showed higher levels of oleic acid with approximately 20% C16:0, 48% C18:1 and 24% C18:2 in all the single-grain samples : the proportion of C18:1 increased at the expense of C18:2. Interestingly, LPE16:0 increased slightly but decreased in the non-starch and starch LPCs of DRFAD2.LPLs were reported to be involved in starch crystallization, which had a physicochemical impact on the starch properties of white rice ,32. BecaS method . The amoectively . In compDRFAD2 showed a 2% increase in the TSC and a 2% decrease in the protein content compared with WTFAD2 flours (DRFAD2 and WTFAD2 flours (2To)  in comparison with WTFAD2.White rice flour was used to determine the main chemical composition of rice endosperm. T flours . The amyT flours . Changesrs (2To) . The temn FAD2DR . In the DRFAD2 and WTFAD2 grains exhibited a consistent pattern composed of about 20% ∑DP ≤10 and 90% ∑DP ≤24 glucan chains and a maximum number of glucan chains at DP12 (CL10/24) of ∑DP ≤10 and ∑DP ≤24 in the CLD profile was almost identical for DRFAD2 and WTFAD2 starches. The only difference was shown by subtracting the CLD of WTFAD2 from DRFAD2. However, the variation was insignificant with just over 0.4% at DP10 and even smaller changes observed at other chain lengths. The subtle changes in the starch molecular structure and composition of DRFAD2 flour suggested the starch accumulation was not affected by the substantial reduction of FAD2 activity or increase in oleic acid in transgenic grains. The variation of starch structure and grain composition of white rice flour between DRFAD2 and WTFAD2 was considered negligible, not significant enough to affect starch properties. Therefore, the alteration of DRFAD2 starch property can be primarily attributed to fatty-acid composition changes.The overall CLD profiles of the debranched starch in both  at DP12 . The ratDRFAD2 suggests that the precursor PC18:1 and PE18:1 accumulated with a low level of PC18:2 and PE18:2 produced because of low FAD2 activity. However, the fatty-acid composition of PC and PE needs to be investigated further. Within the endosperm of DRFAD2 grain, the fatty-acid composition of LPC and LPE are also consistent between starch and non-starch fractions, which are considered as lipids contained in the amyloplast and the ER compartment, respectively. This can be possibly attributed to the extensive trafficking of acyl groups between ER and the plastid, which has been regarded as a key aspect of the eukaryotic pathway [According to the fatty-acid biosynthesis previously described, PC18:1 and PE18:1 are desaturated by FAD2 to produce PC18:2 and PE18:2 at the ER membrane . PC18:1  pathway . In maiz pathway . LPE is sn positions depending on the carbon chain length of the fatty acids [sn-1 position in rice starch LPLs, while C18:1 and C18:2 may occupy the sn-2 position of the glycerol backbone. The linear steric orientation of LPC 16:0 and LPE 16:0 molecules may be more efficient for the ALC formation, while LPC/LPE C18:1 and C18:2 form ALCs in a less efficient manner. Consequently, a greater amount of LPC 16:0 and LPE 16:0 is trapped inside the starch granule during endosperm development than 18-carbon LPC and LPE (C18:1 and C18:2). In contrast, a much lower proportion of C16:0 was found in the storage lipids at the whole seed level than in the endosperm because C16:0 is elongated to C18:0 for further desaturation to C18:1 and then C18:2 by stearoyl–ACP fatty acid desaturase (SAD) in the plastid and FAD2 in the ER, respectively [DRFAD2 endosperm again supports the theory that LPC and LPE originate from ER-derived PC and PE via ER–amyloplast lipid trafficking [DRFAD2 could be compensatory for maintaining sufficient C18:2 content at the whole-seed level [LPC and LPE produced through the eukaryotic pathway exhibit different ty acids ,36. Accoectively . The pleed level .DRFAD2 starch for an unknown reason, it still showed restricted gelatinisation as indicated by the reduction in the swelling-power test, which could be due to an increase in C18:1 and a decrease in C16:0 and C18:2. This is because the crystal structure of rice starch with C18:1 is more ordered than C18:2, and the ALC formed by amylose and C18:1 is more stable compared to C18:2 [Adding lipids to starch with stirring and heating at 65–75 °C in excess water can form ALCs in an exothermic manner during starch gelatinisation . The forto C18:2 . In contw/w) C18:1 or C18:2 was added to maize starch, which was cooked [2Tp and 2Te together with a slight increase in 2∆H of the ALC were detected in the starch with the C18:1 addition [2Tp and 2∆H of the ALC were higher in DRFAD2 than WTFAD2. This evidence indicated high stability of ALCs with C18:1 required a higher temperature to dissociate than the ALCs with a high C18:2 in WTFAD2. The dissociation temperatures of the ALC have been reported to increase along with the length of the carbon chains but decrease with the increasing number of fatty-acid double bonds [2∆H of the ALC is a net effect of increased C18:1 and decreases of C16:0 and C18:2 in starch LPLs of the DRFAD2 grain.In the heat moisture treatment of food processing, fatty acids are blended with starch, and it is believed they can diffuse into the interspace of starch granules and enter the amylose cavity to form ALCs and enhance the crystalline structure with a higher ordering degree . In an es cooked . Althougaddition . In our le bonds ,20,21,22DRFAD2 rice grain were generally in agreement with the TFA changes in the whole grain. The DRFAD2 starch, containing the ALC formed by amylose and LPC/LPE enriched with C18:1, required higher energy to disassociate and exhibit reduced starch swelling power than that of WTFAD2. LPCs and LPEs in the starch lipid fraction were produced from ER-derived PCs and PEs. The study provides an insight into the mechanism of lipid accumulation in a cereal endosperm and the functional properties of ALCs due to the genetic modification of fatty-acid composition.The fatty acid composition changes (C18:1 increased at the expense of C18:2) in LPCs and LPEs in non-starch and starch fractions of the


The close interrelationship between cardiovascular diseases and alterations in glucose metabolism has raised the prospect that atherosclerosis and type 2 diabetes share a common background. Both conditions seem to be based on similar genetic and environmental precursors; this has been termed "common soil" and the American Heart Association explicitly stated in 1999 that "diabetes is a cardiovascular disease".In this context, in 2001 my friend and colleague Prof. Enrique (Zvi) Fisman and I began to consider the possibility of creating a scientific journal specifically dedicated to cover the intersection between diabetes and cardiovascular disorders. The task did not seem to be easy since it was necessary to establish an Editorial Board, obtain an ISSN , register the Journal in PubMed and other repositories of medical information, find and appropriate publisher, publicize the existence of the Journal as widely as possible… and we had no idea how to start and accomplish these tasks.We contacted then BioMed Central (BMC), a United Kingdom-based scientific open access publisher. BMC was then a young and dynamic company, founded in 2000; BMC representatives helped us in each of the initial steps, providing us with guidance and advice. We named the Journal Cardiovascular Diabetology, it was launched on April 2002 and got its first official Journal Impact Factor (JIF) in 2007. BMC is a part of Springer Nature since 2008.As of January 1, 2022, for personal reasons, I will be compelled to step out of my position as Editor-in-Chief. I have taken this decision with sadness, but at the same time with pride as I look at what has been done during these almost two decades. During this period Cardiovascular Diabetology has raised its JIF in a nearly constant yearly pattern, presenting a 2020 JIF of 9.951, ranking it in the 93.45 JIF percentile in the category “Endocrinology & Metabolism”—being thus the leading open access journal in the field—and in the 90.49 percentile in the category "Cardiac & Cardiovascular Systems” journals. The Journal is offered more articles for publication each year and the number and quality of the published articles grow continuously.The Journal is currently facing two new challenges. The first is the recruitment of highly qualified Associate Editors, who will help Cardiovascular Diabetology to publish much more articles and in a quick way. The second is the implementation of SNAPP, the new and sophisticated editorial submission system from Springer Nature, that makes articles’ management smoother and more efficient.None of the above-mentioned achievements would have been possible without the efforts, loyalty and help of countless people. I am aware that the success of our journal is a joint attainment of researchers, authors, readers, Editorial Board members, external reviewers, Journal Development Editors and BMC and Springer Nature scientific and technical teams. I would like to express my gratitude to all of them. It has been an honor and a privilege for me to have been a leading part of this collective initiative.Thank you.


Plant Direct were to make publishing plant research easier and to become the sound science society journal of the plant sciences. One of the ways we have tried to accomplish these goals is to take papers transferred from our partner journals: Plant Physiology, The Plant Journal, and The Plant Cell. Transferring papers saves the authors' time and effort in filling out the meta data associated with each submission—but the real benefits come when the transfers include reviews from the partner journal. With transferred reviews, we can save the authors' and reviewers' time and prevent future rounds of reviews. From Plant Direct's perspective, the more transfers we can get, the better we are able to fulfill our sound science mission and ensure that all good work can find a home in a society journal.Two of our goals when we started The Journal of Experimental Botany (JExpBot) from one of our Societies—the Society of Experimental Biology. The goal of JExpBot is to publish papers “that advance our understanding of plant biology”—a perfect fit for Plant Direct. Authors are now able to port manuscripts declined at JExpBot to Plant Direct with the click of a button. We are looking forward to our partnership!So I am very excited to announce that we have added a new partner journal:


Background: Various factors other than fibrosis could affect liver stiffness (LS), measured by two-dimensional shear wave elastography (2D-SWE). We aimed to clarify the factors affecting LS in local citizens. Methods: We performed a cross-sectional study among local citizens of a health checkup program. Abdominal obesity was defined as waist circumference ≥85 cm for men and ≥90 cm for women. We evaluated the correlation between LS by 2D-SWE (Aplio 500) and waist circumference with linear regression analyses. We selected the following items as variables in the multivariate analysis: waist circumference, sex, hypertension, diabetes, diagnostic components of metabolic syndrome, γ−glutamyl transpeptidase, total bilirubin, NAFLD fibrosis score, and an indicator of a fatty liver, evaluated ultrasonographically. Results: Overall, 345 individuals were included; 318  were analyzed, 128 of whom had abdominal obesity and significantly higher LS than non-abdominally obese individuals. In the multivariate analysis, waist circumference was positively, independently, and significantly correlated with LS only in abdominally obese individuals. Conclusions: Liver stiffness by 2D-SWE could increase with increases in waist circumference in local citizens with abdominal obesity. Physicians should pay attention when assessing the LS of abdominally obese individuals. Liver fibrosis is an essential condition and predicts prognosis . AlthougTransient elastography is a kind of ultrasound elastography that became clinically available the earliest and most widely used than other ultrasound elastography . Liver sHowever, liver stiffness may differ from actual liver fibrosis in some conditions. Breathing, cardiac beats, liver congestion, liver inflammation, cholestasis, and a fatty liver have all been reported to affect liver stiffness . PreviouWe held a cross-sectional study of individuals who participated in a health checkup program held at Kameoka Municipal Hospital in Japan between May 2017 and March 2019. Participants were asymptomatic individuals who voluntarily participated in the program to check their health. Those who had ascites found by abdominal ultrasonography, heart failure, the positive result of a hepatitis B surface antigen test or a hepatitis C virus antibody test, the medical history of alcoholic liver disease, or unreliable liver stiffness were excluded. Those who did not undergo liver stiffness measurement were also excluded. This study was held under the Declaration of Helsinki in 1975 and approved by the Ethics Committee of Kameoka Municipal Hospital (ID 30-3). This study’s consent was obtained by the opt-out approach based on the Ethical Guidelines for Medical and Health Research Involving Human Subjects in Japan.Standardized self-administered questionnaires and medical interviews were used to acquire participants’ age, sex, and comorbidities. The following data were obtained from the results of the health checkup program: body mass index (BMI); waist circumference; systolic blood pressure; diastolic blood pressure; white blood cell and platelet counts; fasting blood glucose, hemoglobin A1c, total bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase, alkaline phosphatase, γ-glutamyl transpeptidase, albumin, blood urea nitrogen, C-reactive protein, total cholesterol, triglycerides, high-density lipoprotein (HDL) cholesterol, and low-density lipoprotein cholesterol; estimated glomerular filtration rate; liver stiffness; the ultrasonographic findings of a fatty liver (UFL) score, indicating a fatty liver’s degree; the NAFLD fibrosis score and the Fibrosis-4 (FIB-4) index, indicating a degree of liver fibrosis. The participants were instructed to fast overnight before undergoing blood tests and abdominal ultrasonography.Trained ultrasonographers performed abdominal ultrasonography. Liver stiffness was evaluated using 2D-SWE   accordinA fatty liver’s degree was semi-quantitatively evaluated using a scoring system with ultrasonographic findings of a fatty liver, the reliability of which has been validated previously . Briefly2). NAFLD fibrosis score = −1.675 + 0.037 × age (years) + 0.094 × BMI (kg/m2) + 1.13 × IFG/diabetes  + 0.99 × AST/ALT ratio − 0.013 × platelet (×109/L) − 0.66 × albumin (g/dL) [9/L) × (ALT (IU/L))1/2) [Hypertension was defined as when a patient was either diagnosed with or under medical treatment for hypertension. Diabetes was defined as when the patient had both fasting blood glucose ≥ 126 mg/dL and hemoglobin A1c ≥ 6.5%, or under medical treatment for diabetes. Dyslipidemia was defined as when the patients were under medical treatment for dyslipidemia or having at least one of the following: total cholesterol ≥ 220 mg/dL, triglycerides ≥ 150 mg/dL, HDL cholesterol ≤ 39 mg/dL, or low-density lipoprotein cholesterol ≥ 140 mg/dL. Fatty liver disease was defined as the patient having a UFL score of 2 or higher. BMI = body weight (kg)/height  and those without abdominal obesity . Abdominal obesity was defined as waist circumference ≥85 cm for men and ≥90 cm for women based on the Japanese diagnostic criteria of metabolic syndrome .p-values; p-values < 0.05 were considered to indicate statistical significance. The Windows version of JMP 14  was used as the analysis software. Univariate and multivariate linear regression analyses were performed to see the correlations between liver stiffness and variables.Categorical variables were presented as percentages (absolute numbers), and continuous variables were presented as means (standard deviations). We performed Pearson’s chi-square tests for comparing categorical variables and Student’s t-tests for comparing continuous variables between the subgroups. Two-sided tests were performed to calculate the n = 2), hepatitis C virus (n = 2), alcoholic liver disease (n = 3), both hepatitis B virus and alcoholic liver disease (n = 1), heart failure (n = 2), both heart failure and unreliable liver stiffness (n = 1), unreliable liver stiffness (n = 8), and unperformed liver stiffness measurement (n = 8). Finally, 318 participants were analyzed  and a higher prevalence of hypertension (p < 0.001), diabetes (p = 0.040), and fatty liver disease (p < 0.001) than the non-abdominally obese group.Overall, 57% of the participants were male, with a mean age of 63.4 ± 12.2 years. Comorbidities included hypertension (41%), diabetes (13%), dyslipidemia (49%), and fatty liver disease (41%). Liver stiffness was 5.79 ± 1.11 kPa, the NAFLD fibrosis score was −1.333 ± 1.217, and the FIB-4 index was 1.60 ± 0.67, respectively. No one had 15 kPa or more of liver stiffness, the cutoff value of 2D-SWE used in this study for diagnosing F4 of the METAVIR score [The following continuous variables were significantly higher in the abdominally obese group than in the non-abdominally obese group: liver stiffness, BMI, waist circumference, systolic blood pressure, fasting blood glucose, ALT, γ-glutamyl transpeptidase, triglycerides, the UFL score, and the NAFLD fibrosis score. The HDL cholesterol levels and the proportion of participants with an NAFLD fibrosis score < −1.455 were significantly lower in the abdominally obese group than in the non-abdominally obese group. There were no significant differences in age, platelet count, and the FIB-4 index between the subgroups .β = 0.28, p < 0.001); BMI ; systolic blood pressure ; diastolic blood pressure ; white blood cell count ; fasting blood glucose , total bilirubin , AST , ALT , total cholesterol , triglycerides , HDL cholesterol ; and the UFL score . The NAFLD fibrosis score and the FIB-4 index were not correlated with liver stiffness.In the univariate analysis, overall, liver stiffness was significantly correlated with waist circumference , BMI , total bilirubin , and the UFL score , but the NAFLD fibrosis score and the FIB-4 index were not positively correlated with liver stiffness. In the non-abdominally obese group, liver stiffness was significantly correlated with age , the NAFLD fibrosis score , and the FIB-4 index , but waist circumference, BMI, and the UFL score were not correlated with liver stiffness  in all participants, whereas β was 0.22 (p = 0.036) in the abdominally obese group. The following items were not significantly correlated with liver stiffness both in all participants and in the abdominally obese group: sex, presence of hypertension or diabetes, systolic blood pressure, fasting blood glucose, triglycerides, HDL cholesterol, the FIB-4 index, and the UFL score. No variables were associated with liver stiffness in the non-abdominally obese group . They reported that HFS had a greater AUROC than the NAFLD fibrosis score and the FIB-4 index in NAFLD patients . BallestWe examined a degree of a fatty liver not with histology but with the UFL score. Though the UFL score’s reliability as an indicator for a fatty liver has been proved in one report , other rTrained ultrasonographers evaluated LS and the UFL score in this study. However, we had not made interobserver agreements of these parameters. The lack of interobserver agreements might have reduced the reproducibility of our study.Since the present study’s participants consisted of individuals who voluntarily participated in a health checkup program, this study may have had a selection bias, unlike a population-based study. Actually, the participant’s average age was higher than the average in Japan. However, the prevalence of hypertension and diabetes in the present study was almost the same as the National Health and Nutrition Survey of Japan (2018) . MoreoveColli et al. reported that liver congestion due to right heart failure was a confounding factor affecting liver stiffness by ultrasound elastography . In thisLiver stiffness by 2D-SWE could increase with an increase in waist circumference in local citizens with abdominal obesity. We think that this correlation might cause the overestimation of liver fibrosis. In such individuals, physicians should not diagnose liver fibrosis only based on high liver stiffness. Physicians should additionally perform low-invasive examinations, including Wisteria floribunda agglutinin-positive Mac-2 binding protein or type IV collagen, before a liver biopsy.


External fixation is a long-standing but well-established method, which has been widely used for the treatment of fractures. To obtain the maximum benefit from the mechanical stimulus, the stiffness of the external fixator should be adjusted properly throughout the treatment phase. Nevertheless, the lack of a valid dynamic adjustable fixation device impedes this possibility. Based on the stiffness adjustment tolerance of the healing callus, this paper proposes an active-dynamic stiffness adjustable external fixator design method to meet stiffness requirements at different stages of the tibial fracture healing process. A novel external fixator with an adjustable stiffness configuration was designed, and the finite element method was used to simulate the stress distribution between fixator and fracture gap. The stiffness adjustment tolerance was determined based on previous studies. According to this tolerance, the optimal block structure dismantling sequence was sought and the corresponding stiffness was calculated through topology optimization for the entire external fixator model. The appropriate amount of variable stiffness at the fracture gap was applied by dismantling the configuration of the block structure external fixator during the healing process. A novel patient-specific adjustable stiffness external fixator for mechanically stimulated tibial fracture reduction and therapy was proposed. This enables surgeons to tailor the construction of the external fixator frame to the clinical needs of each patient. The presented dismantling approach of the block structure to produce conformable stiffness provides a new clinical treatment strategy for tibial fractures. Fracture healing is a physiological multifactorial process affected by the injury characteristics and the mechanical environment and involves both biological and mechanical aspects. It has been well-documented in orthopedic research that the mechanical environment and the motion experienced by a fracture can significantly affect the healing quality –4. StraiOur group has developed a Q-fixator, which has expanded the traditional usage with an automatic reduction function that provides accuracy, minimal invasion, stable fixation, and potential flexible stress adjustment to improve the healing of long bone shaft fracture , 14. BasA 3D geometrical model of tibial fracture was obtained from our previous study Figures . The 3D After the virtual reduction and fixation, a 3D model in STP format of the fractured leg with pins processed by the Geomagic software was imported into Rhino to design the block structure. The division line, which divided the external fixation into front and back parts, was determined based on the position of the pin passing through the fractured leg . VoronoiIn general, the circular frame was attached to the bone through pins or partially threaded half pins. Each frame had three to four mounting holes that were used to connect the frames and bone by inserting pins through them. The two frames were connected by four parallel threaded rods. In this research, the block structure fixator frame comprises two anteroposterior main frame parts that were connected by a thread. This configuration facilitates computer-assisted reduction and fixation. The external load and fixation stability were the main issues of the mechanical environment. The construct stiffness is the pivotal factor that maintains the correct bony alignment under mechanical load. The fixator configurations can substantially change the stiffness properties of the bone-fixator system. Knowing this, an external fixator was designed such that when the stiffness of the fixator needs to be altered, this can be achieved by dismantling the connection rods attached to the block structure. As it can be seen in The pins were externally held by clamps with mounting holes and were also attached to the block structure. The stiffness was controlled by connection elements with different thicknesses , in ordeFE simulations of bone fracture healing were performed to investigate the stress distribution between external fixator and fracture gap during the healing process. An external fixator was adopted to ensure that the stress on the fracture gap can be adjusted by dismantling the block structure. It has been demonstrated that the axial load is shared by the fracture callus and the support device proportionally to the relative stiffness of the fixator and the callus . HoweverIn the present study, the stress distribution on the fracture gap and external fixation can be validated by the following methods. A random point at the same height on the fracture gap and the external fixation cast can be taken, and the stress values at different stages of fracture healing  are observed and recorded. The sum of the stress values on the fracture gap and external fixation cast at different stages of fracture healing can be calculated. If the sum of stress values obtained from a random point from the fracture gap and the external fixation cast at the same height is equal to the axial load applied to the tibial plateau, it can be concluded that the axial load is shared by the fracture callus and the support device proportionally to the relative stiffness of the fixator and the callus. If they are not equal to the axial load applied to the tibial plateau or the stresses on the fracture gap and the external fixation cast do not change proportionally at different stages of fracture healing, it can be concluded the axial load is not equally shared by the fracture callus and the support device and is not proportional to the relative stiffness of the fixator and the callus. In this research, according to the cell phenotypes, the stages of the healing process were divided into six load steps in the Abaqus software. In each load step, different material properties and the same loads and boundary conditions were set. Neither bone resorption nor tissue degradation was taken into consideration.The 3D model of the pinned fracture  after diFracture healing is a complex biological process that can be divided into primary and secondary healing –21. StraThis paper argues that the stiffness of the external fixator can be gradually decreased after the disassembly of the proposed block structure external fixator to the stiffness adjustment tolerance. Consequently, the healing callus will be stimulated by an amount of stress that corresponds to the magnitude of the stiffness adjustment tolerance. The stiffness adjustment tolerance has been determined in the previous section based on existing research, while the dismantling sequence corresponding to the tolerance of the blocks has not been defined.The entire topology optimization process for optimal block structure dismantling sequence seeking and corresponding stiffness calculation is presented in The actual dismantling process was simulated while ensuring convergence to meet the optimization objectives. The objective function was set to minimize the design response of the strain energy and a fraction of 20% of the initial value of the volume. The optimized area was set to the entire external fixator except for the blocks used to support the Kirschner pin  simulation of the fracture healing process in finite element analysis, the stress on the callus of the fracture gap increased progressively, while the stresses in the external fixator decreased continuously; The sum of the two was almost the same as that of the axial load from the weight of the patient (675 N) . This meThe results indicate that a range of stiffness values can be obtained, which depends on the block structure external frame configuration and its components designed in this paper. Through optimization calculation after dismantling of block structures every time, the stiffness of external fixator can be adjusted in a sequence with 8 different levels: 1%, 1.11%, 1.11%, 6.11%, 2.4%, 7.7%, 2.9%, and 0.14% Figures . StiffneExternal fixator frames have been conventionally manufactured with rigid materials, such as aluminum alloys, which are typically much stiffer than the healing bone tissue. This mismatch in the elastic properties of the fixator and the healing bone tissue results in stress shielding, with the former carrying a significant proportion of the applied load and the latter lacking adequate mechanical stimuli for its remodeling. In recent years, with the progress of 3D printing and other manufacturing technologies, more and more new materials, such as polymers, composites, and metals, have been used to manufacture external fixators, facilitating the development of the whole external fixator system. In this paper, the proposed adjustable stiffness external fixator system was manufactured using fused deposition modeling (FDM), which offers a simple, reproducible, and adjustable methodology. The sliced model was inputted into the FDM 3D-printing equipment  for physical printing where PLA (polylactic acid) was utilized as the printing material, which has a good level of both flexibility and strength. More importantly, this main material of the block structure is thermoplastic. Therefore, the column structure that connects the blocks can be dismantled using heating tools. After the physical printing was completed, the model was postprocessed, which includes removing supports, splicing parts, and polishing the surface of the model. It was observed that the printed product has a good effect and truly reflects the original concept. The FDM 3D printer and the final state of the fixator after printing are shown in Whether it is safe to remove the external fixators or not requires an objective assessment of bone healing while the fixator is still in place. In many circumstances, although radiographic assessment of fracture callus formation has grown into shape, doctors still are not certain enough of completely removing the external fixation. This is due to fear that sudden complete removal of the external fixation would cause secondary damage. Therefore, patients are required to wear it for an additional period of time. The external fixator configuration proposed in this paper can well tackle this problem. With the growth of the callus, a well-matched dismantling of the block structure external fixator is performed, and the goal is that the stiffness of the fixator is always compatible with that of the callus until complete fracture healing. A not entirely dismantled block structure can not only adapt to the stiffness of the growing callus but also play a certain protective role. Controlled IFM can be imposed very early after the placement of the fixator frame, when mechanical stimulation is most effective, while the active loading by the patient is least . TherefoThe fixator proposed in this research is a dynamic modulating stiffness construct that can be adjusted throughout the repair process. This design enables the medical staff to regulate the mechanical environment (stiffness) of the fracture gap in the clinical treatment of tibial fracture. Some published papers reported that the stiffness of the external fixator can be adjusted while the device is attached to the patient –37. HowePLA (polylactic acid) was utilized as the printing material, which is low-cost and has a good level of both flexibility and strength. However, time required to simulate and print via FDM additive manufacturing technology may limit the clinical applications of this proposed concept. However, with the development of the printing process and computation tools, the time required to design and manufacture would be significantly improved.There were some limitations in this study. Simulation of the fracture healing process and stiffness calculation for the optimal dismantling sequence after dismantling of block structures are purely computational representations of a biological healing model. Despite all that, reduction and fixation are clinically applied, but clinical validation of stiffness degradation needs to be done later. Future research will be concentrated both on improving of the FE model and clinical aspects of the concept. In parallel, many efforts will be done to completely develop the totally automated design and optimization process and relative computer-aided design software for the customized adjustable stiffness external fixator. In the future application, only the CT scanning data and the body weight are required to generate the FEA simulation model and the adjustable stiffness external fixator configuration, based on which the final customized block structure fixator for printing can be obtained through an automated optimization procedure.A method for designing patient-specific adjustable stiffness external fixator was proposedThe FE simulations revealed that there is an inverse relationship between the stress distribution at the fracture gap and on the external fixator. Therefore, for the external fixation used in the treatment of tibial fractures, the stiffness of the fracture callus is mutually dependent on that of the fixatorBased on the pathological characteristics of the patient in this research, 8 levels of stiffness were applied for mechanical stimulus adaption. The dismantling sequence was provided through a numbered block structure external fixatorThis paper presented a novel patient-specific external fixator with an adjustable stiffness function developed through customized design and fabrication. To the best of our knowledge, this is the first reported patient-specific adjustable stiffness external fixator for mechanically stimulated healing of tibial fractures.


The following power law relationships were obtained for DRX grain size (DDRX) and dislocation density (ρ) vs. temperature-compensated strain rate (Z) or peak flow stress (σP): DDRX ~ Z−0.25, ρ ~ Z0.1, σP ~ DDRX−0.9, σP ~ ρ1.4. The latter, i.e., σP ~ ρ1.4, was valid in the flow stress range below 300 MPa and changed to σP ~ ρ0.5 on increasing the stress. The obtained dependencies suggest a unique power law function between the dislocation density and the DRX grain size with an exponent of −0.5.The features of discontinuous dynamic recrystallization (DRX) in a highly-alloyed austenitic stainless steel were studied at temperatures of 800 °C to 1100 °C. Hot deformation accompanied by DRX was characterized by an activation energy of 415 kJ/mol. The frequency of the sequential DRX cycles depended on the deformation conditions; and the largest fraction of DRX grains with small grain orientation spread below 1° was observed at a temperature of around 1000 °C and a strain rate of about 10 Hot working is a common treatment frequently applied to various structural steels and alloys. One of the most interesting and important phenomena accompanying thermo-mechanical treatment at elevated temperatures is dynamic recrystallization (DRX), which may result in desirable microstructure evolution providing the required combination of mechanical properties of the processed semi-products ,2,3. DepAustenitic steels are typical representatives of metallic materials undergoing discontinuous DRX under hot working conditions ,7. The m−4 to 10−2 s−1 by using an Instron 300XL testing machine with boron nitride as a lubricant.The measured chemical content of experimental austenitic stainless steel includes 0.03% C, 0.4% N, <0.014% Si, 6% Mn, <0.005% P, <0.003% S, 21% Cr, 1.85% Mo, 10% Ni, 0.4% Nb . The steel samples were homogenized at 1000 °C for 8 h followed by multiple hot rolling at 1100 °C with pass strain of 10% to total reduction of 60%  in order to obtain a uniform initial microstructure composed of equiaxed recrystallized grains. The cylindrical specimens of ∅10 mm and 20 mm in height were subjected to isothermal compression tests to a strain of 1 followed by water quenching. A water jet was passed over the specimen just after deformation ceased to fix the DRX microstructure and prevent the development of any post-dynamic recrystallization process as much as possible. The specimens were compressed at temperatures of 800 to 1100 °C at initial strain rates of 10≥ 15° ignoring CSL ∑3n twin boundaries. The dislocation densities were evaluated by means of kernel average misorientation (θKAM), which was calculated with upper limit of 15°, as ρ = 2 θKAM/(b d) [The phase content was studied by X-ray diffraction using a Rigaku Ultima IV diffractometer with Cu Kα radiation  with supplementation by calculations using ThermoCalc software with TCFE7 database. The microstructural observations were carried out at the center portion of the compressed specimens using a Jeol JEM-2100 transmission electron microscope (TEM) and a Quanta 600 FEG scanning electron microscope (SEM) equipped with an automatic electron backscattering diffraction (EBSD) analyzer, incorporating an orientation imaging microscopy (OIM) system with TSL OIM Analysis 6 software. The OIM images were subjected to post-processing clean up treatment setting a minimal number of measured points per grain of 3. The points indexed with confidence index of less than 0.1 were removed from the analysis. They are shown by black points in the figures presented in the paper. The grain size was evaluated as an average of long and short intercepts counting all high-angle boundaries with misorientations of θ AM/(b d) , where bZ = 0.008 in the studied temperature range of 800–1100 °C. The corresponding nearest neighboring particle spacing in the volume can be evaluated as λ = 0.3 d (π/FZ)1/3 [≤ 900 °C and Cr2N at T ≤ 1000 °C. According to ThermoCalc calculations, the fraction of σ-phase increases from 0.033 to 0.14 with a decrease in temperature from 900 to 800 °C, whereas that of Cr2N increases from 0.006 at 1000 °C to 0.02 at 800 °C. The X-ray diffraction analysis of a specimen tested at 800 °C confirms the σ-phase formation 1/3 ; it compormation , althougTypical true stress–strain curves obtained by isothermal compression tests are shown in A, A1, A2, n, β, α ≈ β/n, n2 are material constants, G is the shear modulus, Q is the activation energy for deformation, R is the universal gas constant, and T is the temperature. Taking into account the temperature dependence of the shear modulus [Q = 415 kJ/mol was obtained for hot deformation accompanied by discontinuous DRX under the studied conditions. The obtained activation energy is about 1.5 times more than that of volume self-diffusion [Q value obtained in the present study can be attributed to the large amount of alloying elements in the studied steel. Formal analysis of deformation behavior can be carried out using the following relationships between the flow stress and strain rates .(1)ε˙=A modulus , the expiffusion . Note heiffusion . The rel−2 s−1 (−2 s−1 (The specific deformation austenite microstructures which evolved in the present steel samples during the hot compression tests are shown in −2 s−1 a. In con (−2 s−1 e or at 1 (−2 s−1 f. CommonKAM) irrespective of the difference in DRX fraction in the various specimens  and the DRX grain size (DDRX) for the present steel is shown in P–DDRX relationship obtained for single-phase austenitic steel [The power law relationships between the temperature-compensated strain rate (Z) and the flow stress as well as between Z and the DRX microstructures developed under hot working conditions allow us to relate the parameters of DRX microstructures to the flow stress. Commonly, the peak flow stress can be expressed by the DRX grain size with a grain size exponent of about −0.7. The relationship between the peak flow stress (σic steel  is also KAM in the high-Mn steel and by counting individual dislocations on TEM images for the 304-type steels. It is clearly seen in The development of discontinuous DRX under hot working conditions is caused by work hardening very similar to primary recrystallization. Namely, the high dislocation density in work hardened grains provides driving pressure for the nucleation and growth of DRX grains. In contrast to static primary recrystallization, however, the DRX development does not remove the dislocations completely ,23,24. TThe relationships in −3 s−1, respectively.The deformation behavior was characterized by an activation energy of 415 kJ/mol and was accompanied by discontinuous DRX with the most frequent cycles during deformation at temperature and strain rate of approx. 1000 °C and 10Both the DRX grain size and the dislocation density could be expressed by power law functions of temperature-compensated strain rate, Z, with exponents of −0.25 and 0.1, respectively.Analogously, a power law function was obtained for the peak flow stress and the DRX grain size with a grain size exponent of −0.9. The peak flow stress in the range below about 300 MPa, i.e., under hot working conditions, could be related to the dislocation density with a power law function with an exponent of 1.4, which tended to decrease to about 0.5 on increasing the flow stress to well above 300 MPa, i.e., in the range of cold-to-warm working.The obtained stress dependencies for the DRX grain size and dislocation densities result in a unique power law function for the dislocation density versus the DRX grain size with an exponent of −0.5.The revealed relationships between the flow stress, the grain size, and the dislocation density are applicable for deformation microstructures with different DRX fractions that evolved over a wide range of deformation conditions with various DRX kinetics.The discontinuous DRX behavior was studied for a highly-alloyed austenitic stainless steel at temperatures of 800 °C to 1100 °C. The main results can be summarized as follows:


Starch is a polysaccharide that is stored to be used in different timescales. Transitory starch is used during nighttime when photosynthesis is unavailable. Long-term starch is stored to support vegetative or reproductive growth, reproduction, or stress responses. Starch is not just a reserve of energy for most plants but also has many other roles, such as promoting rapid stomatal opening, making osmoprotectants, cryoprotectants, scavengers of free radicals and signals, and reverting embolised vessels. Biotic and abiotic stress vary according to their nature, strength, duration, developmental stage of the plant, time of the day, and how gradually they develop. The impact of stress on starch metabolism depends on many factors: how the stress impacts the rate of photosynthesis, the affected organs, how the stress impacts carbon allocation, and the energy requirements involved in response to stress. Under abiotic stresses, starch degradation is usually activated, but starch accumulation may also be observed when growth is inhibited more than photosynthesis. Under biotic stresses, starch is usually accumulated, but the molecular mechanisms involved are largely unknown. In this mini-review, we explore what has been learned about starch metabolism and plant stress responses and discuss the current obstacles to fully understanding their interactions. Energy management is vital for plant development, and it is diversely regulated across species depending on life forms and environmental conditions. Photosynthetic reactions in leaves generate carbohydrates that can be immediately utilised as an energy source. However, part of the photosynthetic products in most plants will be stored as transitory starch during the daytime . During More generally, starch acts as a sugar source when photosynthesis is impaired or unavailable, not only in the nighttime but also during seed germination, tuber sprouting, tissue regeneration, or under stress conditions . Starch Stress can affect carbon metabolism by affecting photosynthetic rate, carbon allocation, and night respiration. These impacts can reduce plant growth and development depending on the type of stress and affected tissue. Studies related to the effects of stress on starch metabolism have faced significant challenges because the response depends on the nature, strength and duration of the stress, how gradually it develops, and plant developmental stage and the time of the day and . In addiChanges in the plant starch metabolism due to abiotic stress depend on how the stress affects growth, the relative extent of the inhibition of growth and photosynthesis, and whether modifications in C allocation support stress responses. Each of these factors depends on the type of the stress, its intensity and duration. Early stress responses require resources to provide energy and support the synthesis of new molecules to protect, restore, and acclimate the plant. As photosynthesis is frequently impaired by stress, an important role is played by carbon reallocated from starch, avoiding a significant reorganisation of metabolism . Starch As recently reviewed, transitory starch content is usually observed to decline in leaves in response to salt, drought, and cold stress , consistStarch degradation in response to stress may use different combinations of enzymes, while nighttime degradation uses mainly BAM3 and ISA3. Under water, stress amylase 3 (AMY3) and BAM1 are induced . BAM1 ca+ in its granules  promotes stomatal closure under water, temperature, and osmotic stresses, lowering the internal leaf COpiration . Photorepiration .Starch can also be stored outside source organs as a reserve to be used in a situation of longer-term low carbon assimilation. Reproductive organs seeds or tubers can accumulate large amounts of starch to support the growth of the next generation. However, starch is often accumulated outside source leaves during vegetative growth and can play an essential role in stress responses. A noteworthy example is starch reserves in the woody tissues of the trees, in the xylem-ray parenchyma cells . While lZea mays L. , unlike the starch in mature zones of the leaves, starch levels in the growth zones are kept high at nighttime , reducing grain starch  and Oryza sativa L. , high temperatures reduced the transcript levels of several starch synthesis genes, which are correlated with a reduction in seed size  infecting barley (Plasmopara viticola (Berk. and M.A. Curtis) Berl and De Toni  infecting Vitis vinifera L.   infecting Brassicaceae   , Plasmodsicaceae , as wellanaceae) .Citrus spp. L. (Rutaceae) infected with Candidatus Liberibacter, which causes citrus greening or Huanglongbing (HLB), due to the economic impact of this disease in worldwide orange production  resulted in excessive starch accumulation and overexpression of genes related to the starch synthesis  Keissl.  induce abnormal starch accumulation in Arabidopsis thaliana (L.) Heynh. (Brassicaceae) and Solanum tuberosum L.  (Transient expression of the truncated effector of LasΔ5315 bacteria in ynthesis . Likewisanaceae) , that isanaceae) .Starch levels and gene expression are often analysed only once a day, and the actual time of day is rarely specified, with few exceptions . HoweverCOMPONENT CIRCADIAN CLOCK ASSOCIATED 1 (CCA1) is affected by induction with the flg22 peptide and P. syringae infection, while LHY and TOC1 show salicylic acid-induced increased gene expression   . As the 2 (PRR7) . Mutantsme’s end . Interesd by ABA . Consided by ABA , and OsZd by ABA , the bZIStarch can be an essential carbon source when photosynthesis is inhibited at night and under many stress conditions. The carbon derived from starch may help support some continued growth, but it is probably even more critical because it supports metabolic and cellular responses that ameliorate stress. While the pathways of starch degradation are pretty well-understood in source leaves, less is known about the enzymes involved in starch metabolism in sink tissues under abiotic stress. Furthermore, little is known about the interaction between starch turnover and stress responses, especially when another regulatory pathway, the circadian clock, is involved. In biotic stresses, the molecular mechanisms involved in starch accumulation are mainly unknown. In general, a better understanding of the dynamics of regulators of starch metabolism under different types of stress and at different stress intensities is needed, especially post-transcriptional regulators. A better understanding of how starch is used during different stresses could allow breeding programs or genetic engineering to generate stress-resilient plants, especially starch-based feedstocks.CR, MS, and CH wrote and edited the manuscript. All authors contributed to the article and approved the submitted version.CR was employed by Centro de Tecnologia Canavieira SA. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Total knee arthroplasty (TKA) is a very common surgical treatment approach for severe osteoarthritis. Complications of TKA include loss of range of motion and prolonged analgesic requirement for pain control. Osteopathic manipulative techniques (OMT) have been utilized to address localized muscular stiffness to improve range of motion; however, limited studies directly correlate OMT and TKA recovery. This review highlights the therapeutic benefits OMT can have in the postoperative management of arthroplasty with respect to range of motion, edema, pain perception, and ability to perform activities of daily living. This review revealed the use of OMT would positively influence range of motion by manipulation of localized musculature and can result in decreased demand for analgesics. This can, in turn, shorten hospital stay and return the ability of patients to perform activities of daily living earlier than without OMT. Increased research is needed to strengthen these findings on the benefits of OMT in the postoperative management of arthroplasty. Osteoarthritis (OA) is the most common cause of chronic disability and pain for those aged 65 or older in the United States (US) . A degenTotal knee arthroplasty (TKA) has become the standard approach for the management of severe knee OA when conservative, non-surgical options have failed. According to recent studies, 700,000 knee replacement surgeries are performed annually in the US and are expected to surpass 3.4 million annually by 2030 . Of the Osteopathic manipulative medicine (OMM) is a branch of medicine that was founded on the philosophy that the anatomical body is interconnected to its function and physiology. Somatic dysfunction in one bodily domain can intimately affect others, resulting in pain and disability. Osteopathic manipulative treatment (OMT) is a series of techniques used to diagnose and treat somatic dysfunctions in order to restore homeostasis and return of bodily function . The useMethodsA search was conducted of the National Library of Medicine's MEDLINE/PubMed databases in addition to the Journal of American Osteopathic Association with the intent of finding all relevant articles published in English with keywords “post-operative”, “knee arthroplasty”, “total knee replacement”, and “osteopathic medicine”. All articles were accessed between September 2018 and May 2019 with qualitative data for the systematic review collected. All manuscripts that were published in English in the past 30 years were included, with the earliest in 1996. Journal publications were categorized based on study date to show progression in the field and further coded and analyzed by study type, number of participants, and conclusions to determine any overarching themes or messages. Exclusion criteria included commentaries without obvious scientific research, the non-osteopathic scope of research, inability to obtain the full text, and no English translation of the full text, with full breakdown seen in Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines , followed by case reports (n=3), cross-sectional studies (n=2), literature reviews (n=2), and case-control studies (n=1)  prophylaxis are usually accomplished with medication. Physical therapy can start as early as postoperative day one, with studies showing early mobilization being associated with improved prognosis. Optimal recovery is defined as achieving 90° of knee flexion and full extension one-month post-knee arthroplasty as measured through ROM testing. Many of the studies included multiple complications, with mobility and pain control being the most common , followed by ADLs (n=8), and length of hospital stay (n=5). Of 50 surveyed patients, 52% reported moderate pain one-month postoperative TKA with concomitant use of strong opioids . Other sROM RecoveryOMM and OMT have been studied and used to address common pain presentations in postoperative recovery; however, limited research has been done directly following TKA . In geneLocal musculature can be targeted using the theory of reciprocal inhibition, in which one muscle contracts and the antagonist muscle relaxes to accommodate this motion, leading to overall musculoskeletal and fascial relaxation. Muscle groups of interest in a total knee replacement may include the quadriceps femoris muscle group , as well as the hamstring group muscles  Figure  27]. Wh. Wh27]. OMT has been shown to be beneficial in a focused and localized manner as well as generalized full-body healing. Postoperative ROM restrictions are common, often due to pain, and would often lead to significant sequelae in ADL . In a siEdemaEdema, or swelling caused by trapped extracellular fluid in body tissue, is a common sequela reported in TKA patients, particularly in infrapatellar structures. Postoperative edema can have numerous etiologies ranging from anatomical sources such as surgical trauma to lymphatic channels to physiological reasons such as decreased movement and pain during recovery. Basic OMT manual lymphatic drainage (MLD) techniques include the use of rhythmic alternating pressure, in which pressure is applied in the direction of fluid movement and fascial restrictions are adjusted to move stagnant flow . A complAnalgesia and Daily FunctionPain and its control are often challenging components to tackle in the post-TKA recovery period and often limit a patient’s ability to participate in physical therapy and return to daily activities. OMT has been shown to shorten hospital length of stays and reduce dependency/duration of opioid analgesics, which leads to an overall lifestyle improvement. Prior studies have noted that with regaining preoperative ROM, those in pain tend to have an increased number of postoperative office visits compared to those with resolving pain. Clinical trials with OMT in this recovery period have been shown to be associated with shorter rehabilitation periods compared to standard control groups and had earlier return to activities such as stair ambulation . FunctioFuture outlookBased on the 18 studies reviewed, there is insufficient evidence to determine the true role of OMM/OMT in post-TKA patients. While the benefit of OMM in its application to post-TKA patients can be inferred, many studies did not explicitly include OMM or OMT as a treatment modality, thus limiting a comparative approach to conventional or standardized postoperative treatments. Despite the inclusion of multiple prospective studies, a more definitive clinical trial with control is needed for comparison. OMM/OMT protocols tended to be subjective and personalized, in which reproducibility and the use of double-blinded studies would be challenging. Objective measures for subjective categories such as patient satisfaction tend to produce more variable results, which complicates generalizations. Future research can develop objective measures that assess the improvement or wellness of the patients post-TKA after receiving OMM. Further investigation can also be done with OMT in other common joint arthroplasties such as hips and shoulders, which can expand the role of OMT in the postoperative patient.OMM can potentially provide therapeutic benefits for patients following TKA by inhibiting common pathological processes common in the postoperative period, including muscle hypertonicity, edema, and musculoskeletal dysfunction. OMT, such as muscle energy, myofascial release, strain and counterstrain, effleurage, and lymphatic pump, can provide relief, especially in regard to edema, pain, and restricted ROM, subsequently increasing mobility, which can correlate with decreased length of hospital stay, improved pain control, and greater capability of achieving ADLs. In the current opioid epidemic, alternatives to medical therapy can assist patients in their return to daily activity performance and, therefore, yield positive influences on the mental health of patients postoperatively. While studies provide evidence of the potential benefits of OMT in the postoperative management of arthroplasty, increased research on the benefits of OMT is needed to strengthen these findings. The limited studies included in this review emphasize the importance of additional research in the field of OMM.


An alumina-toughened zirconia (ATZ) material, fabricated using a procedure consisting of the common sintering of two different zirconia powders, was tested using the ball-on-disc method in a temperature range between room temperature and 500 °C. Corundum balls were used as a counterpart. The ATZ composite behaviour during tests was compared with that of commonly used α-alumina and tetragonal zirconia sintered samples. At temperatures over 350 °C, a drastic decrease in the wear rate of the material was detected. SEM analyses proved that, in such conditions, nearly the whole surface of the sliding material was covered with a layer of deformed submicrometric grains, which limited contact with the part of material that was not deformed. The mentioned layer was relatively strongly connected with the material, increased its resistance, and decreased its coefficient of friction. As a reference, commonly used materials, namely commercial alumina and tetragonal zirconia, were tested. The wear parameters of the composite were significantly better than those registered for the materials prepared of commercial powders. Continuous development of ceramics technology is a clear condition for the improvement of many branches of industry . Each ty2, and the second one was a solid solution of 4 mol.% Y2O3 in ZrO2. The raw materials used for the preparation of the powders were zirconyl chloride, yttrium chloride, and ammonia , which were also used for the precipitation process. Both zirconia powders (the pure one and the 4 mol. % of yttria solid solution) were obtained separately and homogenized by milling in a rotary-vibratory mill for 2 h in a propyl alcohol environment. The weight ratios of both powders were established on a level which assured 3 mol.% nominal content of yttrium oxide in the fabricated material. The final composition of the material was supplemented with the addition of 2.3 vol.% (1.5 wt.%) of nanometric alumina powder . The mixing process was performed in a rotary-vibratory mill for 30 min in a propyl alcohol environment. The final material was a composite with a zirconia matrix, with a small addition of nanometric alumina grains. The material was prepared as described and is herein designated as ATZ.The zirconia-based material was prepared for the test using the procedure described by the authors of ,20. CeraSamples in the form of 60 × 60 × 6 mm plates were first uniaxially pressed (50 MPa) and then isostatically pressed at 200 MPa. Then, the samples were sintered at 1450 °C for 2 h. Under the same conditions, samples of commercial zirconia powder containing 3 mol.% yttrium oxide  and samples of TM-DAR alumina powder were pressed and sintered. These samples, designated as Z and A, respectively, were used for tribological tests as comparative materials.Al2O3 = 3.99 g/cm3 and dZrO2 = 6.10 g/cm3). The ATZ theoretical density was calculated as dATZ = 6.01 g/cm3 using the rule of mixtures assuming predicted zirconia and alumina content in the composite.The densities of the sintered samples were determined using the Archimedes method at 21 °C and related to their theoretical values  diffractometer was used. Images of the materials’ microstructures after the tribological tests were obtained with a scanning microscope Nova NanoSEM 200 (FEI Company).The mean grain size of the sintered materials was determined utilizing binarized microstructure images of the polished and thermally etched surfaces of sintered materials. The commercially available program ImageJ was used.v) values were obtained based on the proper standard [s and Wb, respectively. The friction coefficient (CoF) and wear rate  according to the procedure described by the authors of [After the tests, the worn surfaces were examined with an interferometric profilometer ProFilm3D  to estimate the wear rates for the samples and counterparts  of monoclinic phase (baddelleyite) was detected. This material also contained 1.5% of α-alumina. The alumina sample (A) was composed of 100% α-alumina. The results of the XRD measurements are shown in s and Wb parameters values measured for the compared materials. As it could be predicted, sample A showed the worse tribological behaviour. The Ws and Wb parameters of sample A showed the highest values, which were significantly increased with the increasing test temperature. Samples A and ATZ behaved almost identically at low temperatures (up to 150 °C).s and Wb values). However, at 350 °C and at higher temperatures, a sudden decrease in the Ws and Wb values was observed for the ATZ material. Such an effect was not expected because the ATZ material was composed of alumina and zirconia, and these materials behaved separately in a different manner. Alumina and zirconia both showed a continuous increase in the Ws parameter with the increasing temperature. This effect was limited at temperatures over 300 °C but still noticeable. At temperatures ranging from 350 to 500 °C, the wear rate of ATZ was comparable with that observed at RT and at 150 °C. However, a slightly lower maximum wear rate was registered at 300 °C. The changes of the alumina counterpart wear rate were similar for the Z and ATZ materials.At 300 °C, the pure zirconia Z material showed distinctly better properties than the ATZ composite ;-The presence of a small amount of monoclinic zirconia phase in the ATZ material (5%) and its better t→m transformability; and-Ic) for the AZT material [The higher value of critical stress intensity factor  and our ATZ material included:All these factors worked together to improve the ATZ material behaviour in the conditions tested during the ball-on-disc test, which simulated sliding work as a part of real machinery. The ATZ material showed better sliding properties, possibly owing to the formation the pseudo-plastic layer on the working surface, which was much finer than the layer observed in the TZP material made of commercial powder. This layer expanded with the increasing temperature and covered a bigger part of the working material surface. At RT and low temperatures, deformed areas were located as isolated islands on the surface. With the increase in working temperatures to approximately 350 °C, these single islands became a continuous layer. The formation of the layer was correlated with the sudden decrease of sliding wear parameters, which could significantly improve the lifetime of machinery parts made of ATZ composite. In the TZP material, the phenomenon of total surface area increasing of the deformed layer did not manifest such spectacular changes. Most likely, the TZP material was limited by its bigger grain size and worse t→m transformability.The modification of the TZP material (Z) involved the addition of a small amount of α-alumina submicrometric particles and the utilization of the sintering process assisted with intensive yttrium cations migration from using two different zirconia powders, which led to composite materials with a very fine grain size and small amount of monoclinic phase (ATZ).s, Wb) for both elements of the tribological sliding pair over 350 °C was observed. In addition, the coefficient of friction of the ATZ against the alumina ball was significantly decreased at elevated temperatures. These findings confirm that the ATZ composite material manufactured by the proposed technique had a strong potential to be used for reliable machinery parts working in the sliding regime at elevated temperatures. Moreover, the ATZ composite material prepared from mixed zirconia powders could be a better solution than tetragonal zirconia material made from commercial powder due to its distinctly better properties.The experiment proved that the mentioned material significantly improved the wear susceptibility of the TZP/α-alumina tribological sliding pair at elevated temperatures. This was especially effective at a temperature range between 350 °C and 500 °C. In these conditions, the surface layer created during the dry sliding of counterpart on the material surface from room temperature became almost continuous. Such a phenomenon strongly decreased the surface degradation by limiting the removal of single grains. This was detectable as a sudden decrease in the wear parameters (W


Interference screw is commonly used for graft fixation in anterior cruciate ligament (ACL) reconstruction. However, previous studies had reported that the insertion of interference screws significantly caused graft laceration. The purposes of this study were to (1) quantitatively evaluate the graft laceration from one single insertion of PEEK interference screws; and (2) determine whether different types of sutures reduced the graft laceration after one single insertion of interference screws in ACL reconstruction.n = 10 in each group): the non-fixed group, the non-sutured group, the absorbable suture group, the Ethibond suture group and the UHMWPE suture group. Biomechanical tests were performed using the mode of pull-to-failure loading tests at 10 mm/min. Tensile stiffness (newtons per millimeter), energy absorbed to failure (in joules) and ultimate load (newtons) were recorded for analysis.The in-vitro ACL reconstruction model was created using porcine tibias and bovine extensor digitorum tendons of bovine hind limbs. The ends of grafts were sutured using three different sutures, including the bioabsorbable, Ethibond and ultra-high molecular weight polyethylene (UHMWPE) sutures. Poly-ether-ether-ketone (PEEK) interference screws were used for tibial fixation. This study was divided into five groups (P > 0.05). The biomechanical tests demonstrated that PEEK interference screws significantly caused the graft laceration (P < 0.05). However, all sutures  did not reduce the graft laceration in ACL reconstruction (P > 0.05).All prepared tendons and bone specimens showed similar characteristics  among all groups  did not decrease the graft laceration caused by interference screws. Anterior cruciate ligament (ACL) plays an essential role in knee stability. ACL deficiency might cause meniscus tear and articular cartilage degeneration, which seriously affects the function of the knee joint . The goaDuring ACL reconstruction, suturing the free ends of ACL grafts in a whipstitch fashion is a simple procedure, which helps surgeons to handle the graft and maintain an equal tension among the graft strands . PreviouTherefore, we designed this study to (1) quantitatively evaluate the graft laceration from one single insertion of PEEK interference screws; and (2) determine whether different types of sutures reduced the graft laceration after one single insertion of interference screws in ACL reconstruction. We hypothesized that the insertion of PEEK interference screws significantly caused the graft laceration, and sutures might decrease tendon damage during tibial fixation.This study protocol was approved by the ethics committee of our hospital.n = 10), the non-sutured group , the absorbable suture group , the Ethibond suture group  and the UHMWPE suture group . Three kinds of suturing materials were used in the suture groups: bioabsorbable suture , Ethibond suture  and ultra-high molecular weight polyethylene suture . All sutures were of standard Pharmacopeia size (No. 2).Fresh-frozen porcine tibias  and bovine extensor digitorum tendons of bovine hind limbs  were used in our study. Specimens were obtained from a laboratory animal center. Porcine tibias have shown similar biomechanical properties with the adult human knees , 20. Andn = 6), length (30 mm)]. Then grafts were wrapped in 0.9 % saline-soaked gauze until use.The tibias and tendons were thawed to room temperature 12 h before specimen making. A single-stranded tendon was trimmed to a length of 200 mm   interference screw (8mm in diameter and 28 mm in length) was used for tibial fixation in this study. In the non-fixed group, grafts received no intervention (the blank control group). In the non-sutured group, grafts were not sutured but received one single insertion of a PEEK interference screw. In the suture groups, the ends of grafts were sutured using an absorbable, or UHMWPE suture, and then received the intervention with an interference screw. To achieve a central fixation of the screw, an interference screw was inserted between the graft and the tunnel along a guide wire until the screw tail aligned with anterior tibial cortex . After sThe graft was taken out for a biomechanical test using an electronic universal testing machine . Graft laceration and protective effects of sutures on grafts were assessed by pull-to-failure loading tests as previous studies reported  Fig. 2)2). The fP < 0.05 was used to determine statistical significance.All statistical analyses were performed with SPSS Statistics 22.0 . The mean differences between groups were assessed by one-way analysis of variance (ANOVA). P > 0.05)  Table .Table 1P < 0.05). Regarding the failure mode, all grafts in the non-sutured and non-sutured groups were failed by graft rupture, and no grafts were failed by graft slippage. In the non-sutured group, the sites of graft rupture varied . In the non-sutured group, all grafts were ruptured in the insertion site of interference screws.In order to quantitatively investigate the graft laceration, the biomechanical comparisons were performed in the non-fixed and non-sutured groups. The results found that, after one single insertion of a PEEK interference screw, the ultimate failure load in the non-sutured group was significantly decreased by approximately 25 % than that in the non-fixed group . Moreover, no differences were found in terms of tensile stiffness and energy at failure (P > 0.05) among these 4 groups  used for suturing ACL grafts in a whipstitch method did not provide protective effects on grafts.The prognosis of primary ACL reconstruction is determined by multiple factors, including surgical techniques, methods of graft fixation, graft types and postoperative rehabilitation . Among tP < 0.05). In our study, we used PEEK interference screws for tibial fixation, and the outcomes showed that PEEK interference screws caused significant damage to ACL grafts. After one single insertion of a PEEK interference screw, the ultimate failure load of the ACL graft in the non-sutured group was significantly decreased by approximately 25 % compared with the non-fixed group. Therefore, surgeons should consider the tendon damage from screws while preparing the grafts.Most biomechanical tests have shown that metallic or bioabsorbable interference screws provide sufficient fixation strength –30. HoweDuring graft preparation, sutures are usually used for obtaining an even tensioning and equal distribution of forces between the strands of grafts while performing tibial fixation . MoreoveThe bioabsorbable and Ethibond sutures are two of the most commonly used sutures for ACL graft preparation. Ethibond sutures are made of braided polyester with higher strength than bioabsorbable sutures. The UHMWPE suture is a new suture material, which has greater tensile strength than Ethibond sutures , 34. WriDuring the ACL reconstruction, surgeons are more concerned about the fixation strength of ACL grafts. As previous studies , 19 had Several limitations should be addressed to this study. First, though porcine bone and bovine tendons have been frequently considered similar to human knees with regard to BMD and biomechanical properties , 20, it Using an in vitro model, our biomechanical study suggested that the ultimate failure load of grafts was reduced of approximately 25 % after one single insertion of a PEEK interference screw in ACL reconstruction. Suturing the ends of the grafts using different sutures  did not decrease the graft laceration caused by interference screws.


Parvovirus B19 (PVB19) infection has been implicated in allograft failure or dysfunction in solid organ transplantation (SOT) and allogeneic hematopoietic stem cell transplantation , but the literature is limited.Two pediatric patients were diagnosed with PVB19 infection around the time of allo‐HSCT graft failure. Both cases were secondary graft failure and required second allo‐HSCT.There are many risk factors and potential confounders in determining the exact etiology of graft failure after allo‐HSCT. These two cases highlight the importance of including PVB19 in the diagnostic evaluation for graft failure. PVB19 infection may be an important risk factor for allo‐HSCT graft failure. His IVIG replacement therapy overlapped the same time period that the PVB19 infection was recognized and subsequently cleared. Follow‐up PVB19 blood PCR was negative at day +102. At day +105, repeat blood chimerism studies decreased to 9% unseparated and 5% myeloid donor engraftment. Flow cytometry revealed repopulation of original LAD phenotype, confirming secondary graft failure. The patient had autologous immune recovery and his blood PVB19 PCRs remained negative. He received a second allo‐HSCT using myeloablative busulfan and cyclophosphamide followed by G‐CSF mobilized peripheral blood stem cells from the same donor at day +225 from his first allo‐HSCT. At the time of this report, Patient 1 is 23 months status post his second allo‐HSCT with no evidence of GVHD or underlying LAD. He remains 100% donor by unseparated, myeloid, and lymphoid chimerism. He has had no recurrence of PVB19 viremia following his second allo‐HSCT.2.2A 13‐year‐old male with high‐risk acute myeloid leukemia (AML) received myeloablative conditioning followed by a haploidentical sibling bone marrow graft  and the patient was maintained on monthly IVIG 0.5 g/kg until he had evidence of T‐ and B‐cell immune reconstitution 8 months later. Over a course of 12 months, his blood PVB19 PCRs declined to a low level of detection (<199 copies/mL) but were never negative. With documented immune recovery, response to vaccinations, and no evidence of residual cytopenias or graft dysfunction, blood PVB19 PCR surveillance was stopped. At the time of this report, Patient 2 is 26 months status post his second allo‐HSCT, without evidence of recurrent AML or chronic GVHD, and remains 100% donor across all chimerism studies.He received a rescue allo‐HSCT from the same donor with G‐CSF mobilized peripheral blood stem cells following nonmyeloablative conditioning with fludarabine, cyclophosphamide and 400 cGy TBI. Patient 2 achieved neutrophil and platelet engraftment after second allo‐HSCT at days +15 and + 33, respectively, with 100% donor engraftment by unseparated and lineage‐specific chimerism analysis. His second allo‐HSCT course was complicated by acute gastrointestinal GVHD that resolved with low dose systemic steroids (0.5 mg/kg/day) and extracorporeal photopheresis (ECP), as steroid‐sparing therapy. PVB19 blood PCRs remained positive at low levels until a single negative PCR resulted at day +54 after second allo‐HSCT. At day +68, his blood PVB19 PCR was again detected (<199 copies/mL) and persisted at this level until day +166 when viral loads began to increase (96 400 copies/mL). By day +174 after second allo‐HSCT, he was readmitted with unexplained fever and found to have a PVB19 PCR viral load of 1.38 × 103PVB19 infection is a rarely reported complication following SOT or allo‐HSCT. Cases of allograft loss or dysfunction have been reported following SOT and allo‐HSCT, but the literature is limited. The two cases described in this case report add to existing rare reports of PVB19‐associated graft failure after allo‐HSCT.The first report of PVB19 infection after renal transplantation was published in 1986.Rare cases of PVB19 infection during allo‐HSCT have been reported in the literature. One case described a 14‐year‐old girl with acute promyelocytic leukemia who had abrupt onset pure red cell aplasia induced by PVB19 after an HLA‐matched bone marrow transplant.Allograft loss or dysfunction can be a devastating and life‐threatening complication of SOT or allo‐HSCT. In a systematic review of the literature summarizing cases of PVB19 infection after SOT (n = 74) and allo‐HSCT (n = 24), allograft loss or dysfunction occurred in 10.4% of patients.We report two cases of diagnosed PVB19 infection and secondary graft failure after allo‐HSCT. Recognition of PVB19 infection as a possible risk factor for graft failure is important for diagnostic consideration. Anemia in the early post‐HSCT period is expected and unless other symptoms or complications develop, PVB19 is rarely considered. Allo‐HSCT patients may not manifest with typical rash and joint pain due to an inadequate immune response or when symptoms are present, those symptoms are often attributed to donor cell engraftment. One report described two cases of erythematous rash in two PVB19 positive immunocompromised patients early after allo‐HSCT.Recipients of SOT and allo‐HSCT are at risk for PVB19 infection due to poor immune globulin production and T‐cell function during the post‐transplant period and while on immune‐suppressing therapies. Intravenous immune globulin (IVIG) is considered the only treatment option for PVB19 infection. IVIG treatment targets associated anemia, not fulminant graft failure or dysfunction, and there is significant risk for relapse of anemia.There are many potential risk factors and confounders for graft failure after allo‐HSCT such as underlying disease, type of conditioning, graft source and infused cell doses, infections , and drug toxicities. These potential confounders could limit the association of PVB19 infection and graft failure. Patient 1 in our report received reduced intensity conditioning but had no other identifiable risk factors for graft failure. Patient 2 received a haploidentical graft, had low level CMV viremia, and received ganciclovir and valganciclovir in the early post‐engraftment period; all potential contributors to graft failure. Although we cannot exclude the potential impact of CMV viremia and drug‐induced toxicity in Patient 2 on graft failure, he received his second allo‐HSCT from the same sibling haploidentical donor and engrafted without incident. The only unifying feature of graft failure between our two cases was PVB19 infection occurring early after first allo‐HSCT.In this report, we describe two cases of PBV19 infection associated with secondary graft failure after allo‐HSCT. These cases add to the limited existing literature and highlight the importance of including PVB19 infection in the diagnostic evaluation for graft failure after allo‐HSCT. Quantitative PCR for PVB19 should be incorporated into comprehensive infectious and immunological testing to evaluate etiology of graft failure after allo‐HSCT. IVIG may be beneficial in the management of patients with PVB19 infection after allo‐HSCT but is unlikely to reverse fulminant graft failure occurring early after allo‐HSCT.The authors have stated explicitly that there are no conflicts of interest in connection with this article.Nabila Rattani: Conceptualization; writing‐original draft; writing‐review & editing. Christina Matheny: Conceptualization; writing‐original draft; writing‐review & editing. Michael Eckrich: Conceptualization; writing‐original draft; writing‐review & editing. Lisa Madden: Conceptualization; writing‐original draft; writing‐review & editing. Troy Quigg: Conceptualization; supervision; writing‐original draft; writing‐review & editing.No institutional review board approval was required as retrospective review of two patient cases for publication is not considered human subjects' research consistent with US Federal Policy for the Protection of Human Subjects. Therefore, no patient consent was required.