One third of the food produced in the world is wasted. Bread is one of the most wasted foods both during the distribution process and in households. To use these breads, it is necessary to get to know the properties of the flours that can be obtained from them. The purpose of this work is to know how the type of bread and its zone (crumb or crust) influence the characteristics of the flours obtained from the wasted bread. For this, flours made from the crumbs and crusts of eight different breads have been analysed. Their hydration properties, cold and post-heating rheology and gelling properties as well as the colour of flours and gels have been studied. Bread flours present higher water-holding capacity (WHC) and water-binding capacity (WBC) values and higher elastic modulus (G’) and viscous modulus (G”) values, both in cold conditions and after heating, than wheat flours. However, they generate weaker gels. Crust flours, and the gels obtained from them, are darker than those from crumbs and their gels. In terms of hydration and rheology, pan and wholemeal bread flours are generally lower than other bread flours. These flours also generate softer gels, possibly caused by the dilution of starch with other components. It can be concluded that the properties shown by wasted bread flours allow them to be reintroduced in the food chain as an ingredient in different products. It is estimated that one third of the world’s food production is wasted. In Europe, this represents 88 Mt or almost 175 kg per person per year, which amounts to about EUR 143 billion . It is kThe European Union advises that when it is not possible to minimise it, food waste should preferably be allocated to human consumption, either directly or after its conversion into new products . HoweverIn the baking process, since flour is hydrated and heated and thus allows the denaturation of gluten, it loses baking aptitude and starch gelatinisation. These processes are different in breadcrumbs and bread crust due to the faster drying of this area and the higher temperatures reached in baking, contributing to Maillard and sugar caramelisation reactions ,14. AlthThe aim of this work is to analyse the characteristics of flours from stale breads (SBs), taking into account the differences between several types of breads and also between the internal (crumb) and the external (crust) parts of the breads. Therefore, eight types of breads that differ in their ingredients, sizes of pieces and hydration of the dough have been selected, and the properties  of the flours obtained from their crumbs and crusts have been assessed. These properties were compared with those of a commercial wheat flour.Bread and strong wheat flour were purchased at Carrefour hypermarket in Palencia (Spain). All bread was purchased twice, on different days, at least two weeks apart, to have a repetition. The main ingredients of the breads are shown in To perform the analyses, crumbs and crust were separated from the bread and left to dry on trays at room temperature for 24 h. They were later milled in an LM 3100 hammer mill .The particle size of the flours was evaluated using the particle size analyser Mastersizer 3000 . The values of D  represent the equivalent spherical diameter of the particles. The measurements were taken in duplicate.Photographs of the flour particles were taken with a scanning electron microscope (SEM), Quanta 200FEI . Microphotographs were obtained in secondary electron detection mode at 3 KeV under high vacuum conditions with a backscattered electron detector (BSED).The colour of the flours and gels was measured with the PCE-CSM 2 colorimeter  employing the D65 Illuminant with a 2° Standard Observer. The parameters determined were L* (lightness), a* (green–red axis) and b* (blue–yellow axis). All flours and gels were measured in duplicate.Water-holding capacity (WHC) is defined as the amount of water retained by a sample in the absence of stress. Swelling volume (SV) is the increase in volume occupied by a given amount of sample after undergoing hydration. Both parameters were measured according to de la Hera et al. (2013) , with ceWater-binding capacity (WBC) is the amount of water retained by a sample after it has been subjected to centrifugation. This parameter was measured in duplicate according to method 56-30.01  with modWater absorption index (WAI), the grams of sediment per gram of sample, was determined following the method of Rosell et al. (2011)  with modAll measurements were carried out in duplicate.® Analyser RVA-4C , with 12 g sample and 25 g distilled water, at 30 °C. The paddle speed was 960 rpm for the first 10 s of the analysis and then kept at 160 rpm throughout the process, which lasted 3 min. This process was performed in duplicate.For the evaluation of rheology, pastes were prepared using the Rapid ViscoFor the analyses of dough rheology under heating conditions, pastes were also prepared with the RVA. First, 5 g of sample was added to 25 mL of water. The mixture was heated to 50 °C for 1 min and then to 95 °C, with a rate of temperature increase of 12 °C/min. Once 95 °C was reached, the temperature was maintained for 2.5 min, after which the suspension cooled down to 30 °C at the end of the analysis. The rotational speed was 960 rpm during the first 10 s of the analysis and was subsequently maintained at 160 rpm throughout the process. This process was performed in duplicate.Rheological measurements were performed with a Haake RheoStress 1 controlled-stress rheometer , equipped with a Phoenix II P1-C25P temperature control unit. Here, 80-mm diameter parallel titanium plates with rough surface geometry were used in order to avoid the displacement of the sample. Vaseline was applied during the analysis  to prevent the sample from drying. After allowing the sample to stabilise for a period of 500 s, a strain scan (0.1–100 Pa) with a constant frequency, 1 Hz, was performed to determine its linear viscoelastic region. For the characterisation of the samples, the following were calculated: G’ or elastic modulus (Pa), G’’ or viscous modulus (Pa) and tangent δ (G’/G’’).The measurements were carried out in duplicate.Texture of the gels was measured with the TA-XT2 texture analyser , equipped with the “Texture Expert” software. A penetration test was performed, in which a P/6 probe (SMS Genuine Parts) penetrated 5 mm into the gel, with a test speed of 0.5 mm/s (1 mm/s as pre- and post-test speed) and a penetration distance of 40 mm, in order to determine the gel strength. Gel colour was measured as flour colour. The measurements were carried out in duplicate.p < 0.05) with Statgraphics Centurion XVII software . Two factors were considered: the type of bread and the area of the bread (crumbs or crust) used to obtain the flours. Significant interactions between both factors were found in none of the parameters involved. Pearson correlations were also carried out to identify relationships among the factors studied.Data were subjected to a multivariate analysis of variance (MANOVA) using the Fisher LSD (Least significant difference) test  and browner . The higher temperatures reached in the external part, which facilitate the development of the Maillard and sugar caramelisation reactions, explain these differences . RegardiHydration properties are quality parameters of flours related to their suitability for the production of goods such as biscuits, as they are directly related to the rheology of the doughs and the expansion of these in the baking process ,33.As shown in Although significant differences were observed between the various types of breads, more so in the WHC or SV than in the WBC, these are scarce. The higher WHC values of the small breads and, especially, the lower values of the pan loaf are noteworthy. The higher values of the small breads may be related to the shorter baking times they require as a result of the shorter distance between the external area and the centre and the possible reduction in starch degradation phenomena and subsequent changes in cooling . NeverthAs for WAI, water absorption after heating, no difference was observed between SB and wheat flours. This may be due to the fact that during heating with water, starch gelatinisation in the flour increases the water absorption capacity, in the same way that starch gelatinisation during the baking process does for SB. In contrast to hydration properties in cold conditions, in the WAI, significant differences were observed between crumb and crust flours, with crumb flours being superior. These slight changes may be related to the modification of the small fractions of starch that remained ungelled and can be observed in the microstructure, as mentioned. With regard to the different types of bread, the lower values of WAI in pan and wholemeal loaf flours, both with a lower starch content resulting from the addition of bran or other ingredients, can be highlighted. This confirms the role of gelled starch in hydration properties. Ciabatta flour has the highest WAI value, followed by the classic loaf, but these differences do not exceed 0.55 in most breads, except for wholemeal and pan loaves.The rheology of doughs made from SB flours is shown in The rheological values of the doughs are closely related to the water absorption capacity of the flours. In fact, pan loaf flour, with the lowest values of viscosity, G’ and G”, was also the one that gave the lowest values of WHC, SV and WBC, while the classic loaf flour  was the one that obtained the highest values of WBC and SV, and WHC was the second highest. In fact, significant correlations (99% at least) have been found between WHC and WBC values and G’, G” and Tg δ, with r values higher than 0.70.In the literature, various articles explain the possible differences between the rheology of doughs in term of the effect of certain ingredients, but it must be taken into account that these changes are related to the formation of the gluten network and the effect of these ingredients on this network. However, in the case of SB flours, gluten is denatured to obliterate the capacity to form a viscoelastic network. Therefore, the rheology of these doughs is more related to their composition and the thickening power of the different components, especially starch. Thus, the differences observed between the doughs may be due to the presence of components that reduce this thickening capacity, such as oil in the case of pan loaf or bran in the case of wholemeal loaf. However, these differences can also be caused by the degradation of gelatinised starch by excessive treatment, as discussed in the case of hydration properties, or by the enzymatic hydrolysis of starch , either As can be seen in As with cold rheology, the G’ and G” values of doughs after heating correlate with hydration values, but, in this case, with those obtained after heating (WAI). In the case of G”, the correlation is significant at 99% (r = 0.62), while for G’, at 95% (r = 0.58), and therefore, the correlations are somewhat weaker than those found for cold properties. The rheological properties under heat are influenced by starch gelatinisation processes, which can explain the differences between crust and crumb since, unlike crumbs, there are a small number of ungelled starch granules in the SB crust flours. However, starch retrogradation reactions, especially amylose, also have an influence. In this case, the presence of other ingredients in the bread and the decrease in the amount of starch, as in wholemeal breads and pan loaves, could explain the lower values of these breads. On the other hand, the presence of bran particles may interfere with the creation of a more compact and ordered structure, which would explain the lower values of these flours. The differences between the other bread types, as has already been mentioned for other factors, may depend on starch degradation phenomena during the baking process, which will depend on the amylase activity, pH of the doughs and fermentation and baking times. Thus, the flours with the highest values are those of “candeal” bread, made with low hydration (less than 50 parts of water for every 100 parts of flour) and small breads (with shorter baking times). Therefore, it seems that these factors can minimise the degradation of starch, although further studies would be needed to confirm this. Except for these breads, differences between the rest of the bread flours and flours from classic bread—the most widely produced and from which the greatest waste is generated—are scarce, although in some cases, they are significant.Regarding the hardness of the gels, those obtained from SB flours present lower values than those obtained from wheat flour. This is reasonable since the ability to form gels in wheat flours relies on the starch, and the baking process partially degrades this starch by reducing its ability to gel. Gels obtained from crust flour are somewhat harder than those obtained from crumb flour. This corresponds to the higher water absorption values (WAI) of crust flours under heating, as opposed to crumb flours. The reason for these higher values is that the small percentage of starch granules that have not degraded or have degraded to a lesser extent in the baking process within the crust increase the hardness of the gels when heated.Among the different breads, the hardest gels were obtained with “candeal” bread and small breads, while with the wholemeal and pan loaves flours, hardly any gels were obtained, only a viscous dough with a low resistance to deformation or a very weak gel. In the production of gels, firmness increases with time due to the changes that amylose undergoes after gelatinisation, from a more amorphous structure to a more ordered and crystalline state . HoweverThe previous degradation of starch, such as that produced by acidification , also reAs mentioned, the hardness of the gels obtained is related to the gelatinisation reactions of the starch and to its amount in the sample. In fact, significant correlations have been found between this parameter and most of the hydration and rheology parameters studied, also related to starch and its modifications. Among the hydration properties, the correlation between the hardness of the gels and both WHC (r = 0.76) and WAI (r = 0.73) stands out. Regarding the rheological properties, as would be expected, the highest correlations are found between the hardness of the gels and the rheology of the pastes after heating. Specifically, there are significant correlations at 99.9% between G’ (r = 0.86) and G” (r = 0.92) and the hardness of the gels obtained.Flours obtained from stale bread have shown a greater capacity to absorb water under cold conditions and the G’ and G” values of their doughs are higher than those of wheat flours, but they possess less gelling power. In this work, it is also shown, for the first time, that the characteristics of different commercial breads in terms of hydration properties, rheology of the pastes or doughs obtained in cold or hot conditions and gel properties are quite similar. Therefore, different breads produced in the same facilities could be mixed to obtain flours with homogeneous characteristics. However, those breads containing ingredients such as fats, oils or bran should be excluded, and other factors which, in specific cases, may modify the characteristics of the flours should be taken into account, such as previous enzymatic, heat or acidic degradation. It has also been proven that despite the differences of crumb and crust flours both in colour—due to the Maillard and caramelisation reactions developed in the baking process—and microstructure, these differences do not translate into substantial ones in the rheological properties of the flours obtained. Finally, it has been observed that in these cases, a simple analysis such as that of the WHC or WBC (WAI for hot properties) can predict, or give an idea of, the rheological properties of the flours, which are usually measured with more complex and expensive equipment. This would facilitate the quality control of these flours. These results can be very useful for reusing breads that have gone stale or been wasted in distribution, thus reintroducing them into the human food chain to produce biscuits, batters or other products.


Caregiving is often considered stressful, even more so if the care recipient has been diagnosed with dementia. The current study examines the rate of cognitive decline of spousal caregivers of persons with dementia (CG-D) when compared to spousal caregivers of persons without dementia (CG) before and after the death of the care recipient. Health and Retirement Study (HRS) data from 1998-2016 were used to examine cognitive trajectories of CG-D (n=364) and CG  before and after the care recipient death. Cognition was measured through the HRS’s shortened Telephone Interview of Cognitive Status and separated into measures of total cognition and memory. Covariates included age, education, sex, race, ethnicity, care hours, frailty, socioeconomic status, nursing home placement of the recipient, and whether the death was expected. Piecewise mixed models were constructed to examine two two-year periods of decline leading up to the death of the care recipient, and two two-year periods of decline after the death of the care recipient. CG-D and CG declined at equivalent rates on measures of total cognition and memory (ps > .05). In all caregivers, total cognition and memory declined at a stable rate before the death of the care recipient. However, an accelerated decline was evident after the death of the care recipient (ps < .001). Our results suggest that cognitive decline is not differentially affected by care recipient dementia diagnosis. We find evidence that the death of a spousal care recipient is accompanied by hastened cognitive decline in our population-based sample.


Industrial application of starch as a texture-forming agent is primarily limited to preparations obtained from waxy corn and potatoes. The main reason behind this is its functionality, which depends mostly on rheological properties. However, in food product matrices, these properties change. Despite the vast amount of information on the rheological properties of various starches, the rational choice of thickener appears to be an extremely difficult task. The aim of the work is to systemize the information on the rheological properties of most popular starches in matrices of various food products, applying principal component and cluster analyses. The investigated material is potato and corn starch of the normal and waxy varieties. Binary mixtures containing salts or sweetening agents, as well as four different food products , are investigated. It was found that compared to normal varieties, waxy starches reveal many similar rheological properties in all investigated models and food systems. Furthermore, in most applications, one waxy starch variety may be substituted by another, with no significant impact on the rheological properties and texture of the food product. Moreover, waxy starch preparations are less altered by the presence of cosolutes, i.e., salts and sugar alcohols. Starch model systems were proven to be useful only for rapid thickener screening tests and cannot be recommended as a final reference for the quality design of food products. The importance of starch in food production is not limited to be the main source of energy in human nutrition. It is the most popular texture-forming agent, which is related to its appropriate physicochemical properties, the safety of use, and low price. Starches of different botanical origins reveal a huge diversity in their structure and composition, including their amylose-to-amylopectin ratio and minor  constituent content. As a consequence, they display various functional properties such as thickening capability, gelling or stabilizing ability, and transparency . MoreoveA number of different factors determine the functionality of starch as a food thickener and stabilizer. Nevertheless, analysis of its rheological properties is a primary method used for the examination of this biopolymer in both industry and scientific studies . A numbePhalaris canariensis L. or Solanum lycocarpum [The most important technological information provided by rheological measurements are gelatinization temperature, viscosity, and rheological stability . These have been extensively studied in terms of both native and modified starches, as well as their interaction with low molecular mass solutes and high molecular mass hydrocolloids. Most of all, common commercial starches such as corn, wheat, potato, cassava, or rice have been thoroughly examined ,8,9,10. cocarpum . A huge cocarpum ,16,17,18cocarpum ,20,21,22cocarpum ,24, pullcocarpum ,26, and cocarpum ,28, as wcocarpum  or aminococarpum . InteresStudies concerning the interaction of starch with salt ,32, acidThe enormous amount of diverse information makes it difficult to come to general conclusions regarding the effect of different solutes on the rheological properties of starch. Therefore, the aim of this work is to systemize information on the rheological properties of the most popular starches in matrices of various food products, applying principal component and cluster analyses. Starches used in the study were limited to the most popular in food production, i.e., potato and corn of normal and waxy varieties. Binary mixtures containing salts (NaCl and KCl) or sweetening agents  were analyzed. Moreover, the functionality of these starches in different food products, i.e., ketchup, mayonnaise, pudding, and jelly, was studied. The data presented makes it possible to compare the effect of different factors on starch rheology and may be helpful with the rational choice of thickener for food production.Commercial native starches: potato , waxy potato , corn, and waxy corn  were the base working materials. All analyses were performed on a starch dry matter basis.Binary mixtures were prepared based on analytical-grade reagents and purified water (<0.1 µS/cm).Ketchup: 60 g tomato paste (30 ± 2% dry matter), 25 g sucrose, 12 g vinegar (10%), 6.5 g starch, 3 g salt, 0.2 g finely milled black pepper, water up to 200 g.Mayonnaise (low fat): 125 g water, 120 g rapeseed oil, 17 g sucrose, 14 g starch, 10 g vinegar (10%), 10 g dried egg yolk, 6 g mustard, 3 g salt.Pudding: 20 g sucrose, 18 g starch, 250 g milk (3.8% fat).Jelly: 20 g starch, 12.5 g sucrose, 1 g citric acid, water up to 250 g.Model food systems were prepared according to the following formulas:Ketchup: All ingredients, excluding vinegar, were mixed with an overhead stirrer  operating at 150 rpm. Raw ketchup samples were placed in a boiling water bath for 15 min. Vinegar and evaporated water were added at the last stage of ketchup preparation. Prepared samples were stored for 24 h at 4 °C prior to analysis .Mayonnaise: Prior to the preparation of the emulsion, a starch suspension was pasted along with water, sugar, and salt. The emulsion was ground in a semicircular bowl (9 cm radius) with a twin shaft mixer (400 W). Oil was added gradually (during 1 min) to avoid phase separation. Vinegar and mustard were added at the last stage of mayonnaise preparation. Ready mayonnaise was mixed for an additional 1 min. Further analyses were made on products stored for 24 h at 4 °C .Pudding: Starch was suspended in 50 mL of cold milk and poured into boiling milk (mixed with sucrose). Afterward, the pudding was mixed with an overhead stirrer  operating at 150 rpm and boiled for an additional 5 min. Prepared samples were allowed to set at room temperature for 1 h prior to the analysis .Jelly: All ingredients were mixed together with an overhead stirrer  operating at 150 rpm and placed in a boiling water bath for 15 min. Prepared samples were allowed to set at room temperature for 1 h prior to the analysis .Model food systems preparation procedures:Pasting characteristics of 5% starch suspensions and binary mixtures were recorded with a Brabender Viscograh . Standard measurement parameters were set: measuring cartridge 0.07 Nm, a heating and cooling rate of 1.5 °C/min (within the 25–92.5–25 °C range), a holding period of 20 min at 92.5 °C. The following pasting parameters were analyzed: pasting temperature °C, final viscosity BU, breakdown BU, and setback BU.−1 shear rate range, and time of 2 min. Obtained flow curves were described with the Ostwald de Waele equation:τ is shear stress Pa, K is the consistency index Pa∙sn, γ is the shear rate s−1, and n is the flow behavior index (a dimensionless number that indicates the closeness to Newtonian flow).Rheological properties were determined using a RheoStress1 rheometer  before the measurement samples were thermostated at 20 °C and relaxed in measuring cylinder for 5 min. Data collection and calculations were made using RheoWin 3.61 software. Measurements were performed under the following conditions: Z20 DIN Ti coaxial measurement system, 1-600-1 sUniversal texture profiles  were determined with a TA-XT2 texturometer . A standard “double bite test” was performed with an aluminum cylindrical head (35 mm diameter) in a 68-mm diameter vessel on a depth of 20 mm with a speed of 0.5 mm/s. Hardness (N), adhesiveness (N∙s), cohesiveness, springiness, and gumminess (N) were determined.All analyses were performed in triplicate, and the results are presented as mean ± standard deviation. Experimental data was studied using a one-way analysis of variance and Tukey’s post hoc test. Principal component analysis (PCA) was performed based on the correlation matrix. Cluster analysis (CA) was conducted based on Ward’s method, and the Euclidean distance was used as a measure of similarity. The statistical analyses were performed using Statistica 13.3 software .2) exceeded 0.98. Both normal starch varieties were characterized by higher values of the consistency index compared to their waxy counterparts. This phenomenon could be associated with the lack of gelling properties of waxy starches, which is related to the lack of amylose, thus resulting in relatively low viscosity of these preparations, especially at low shear rates. The convergence to Newtonian flow indicated by the flow behavior index was similar for all samples characterized by a high type of swelling characteristics. The significantly lower value of this parameter recorded for normal corn starch is the result of low resistance to higher shear forces, which can be related to the strong gelling properties of this preparation. Similar observations regarding the differences between normal and waxy varieties of the same botanical origin can be drawn from the analysis of universal texture profiles  was observed between the consistency index and final viscosity, which should be attributed to the difference in shear forces applied in those studies.The differences and similarities between the rheological and texture properties of investigated pastes were also confirmed by PCA analysis . Two firHierarchical cluster analysis  strengthSodium chloride is used extensively in food technology as an ingredient that improves the sensory perception of a vast majority of food products. As a result, many populations consume significantly more salt than the World Health Organisation recommendation. Unfortunately, high sodium diets are associated with the risk of cardiovascular diseases, especially related to high blood pressure . Due to Principal component analysis performed for starch pastes containing salts  shared mThe PCA score plot A shows tThe cluster analysis dendrogram for starch–salt binary mixtures  showed mInterestingly, the effect of the cation type was dependent on the presence of amylose. In the case of potato and corn starches, the influence of the presence of salt on clustering was obvious—binary mixtures were more closely linked compared to pure starch paste. However, in the case of waxy starch varieties, binary mixtures containing potassium chloride were more closely linked than any other sample. This phenomenon can be partially related to differences in the influence of potassium and sodium ions on starch pastes. However, this was predominantly a result of a much lower impact of salts on the rheological properties of amylopectin-only starches compared to normal ones.Sucrose has been, traditionally, the most popular sweetener. However, the negative effects of excess sucrose consumption, such as type 2 diabetes, obesity, and poor oral health, has led to the replacement of sugar by sugar alcohols . Sugar aPCA plots for starch pastes containing sugar and polyols are presented in The influence of the investigated polyols on clustering  shared mFood products are a complex matrix of a vast amount of substances that may significantly influence starch-thickening properties . TherefoThe most coherent group regarding different food products was observed for ketchup (brick-red color), although mayonnaise thickened with waxy corn starch was also included in it. The most similar products in this group were, predictably, ketchup thickened with waxy starches. The similarity of mayonnaise with waxy corn starch to ketchup in this study should not be a surprise, as commercially prepared low-fat mayonnaises are usually thickened with a chemically modified variant of this starch. Despite the fact that mayonnaise is an emulsion and ketchup is a suspension type of sauce, their sensory mechanical properties are quite similar. In turn, the larger distance from this cluster, towards other mayonnaises, may have resulted from undesirable changes in texture that are caused by other starch variants, which are not recommended for this type of product as they may develop a gelatinous texture .Jelly-type deserts were divided into two clusters. One small cluster contained only jellies prepared with waxy starches (dark green). A second larger cluster, apart from jellies prepared with normal starch varieties, included puddings thickened witch waxy starches (orange). The observed clustering is the effect of two factors: gelation of jellies containing starches with amylose and the formation of pudding curd. Eventually, the differences with the last cluster containing pudding prepared with normal starches (yellow) may be attributed to the synergism of amylose and milk proteins, resulting in the formation of strong pudding curd.The food product clustering was consistent with the data presented for the PCA score plot A. HoweveContrary to the score plot, the presented loadings B provideThe aforementioned observations regarding the different types of food products demonstrate the complicated task of technologists in choosing proper thickener. The complexity of food colloidal systems and the vast amount of interactions hinder the selection of the right solution, which is perfectly shown by the dendrogram presented in The functionality of native starches in food systems is a result of numerous factors that influence the efficiency of the preparation and quality of the final product. Native potato and corn starches are significantly different in their physicochemical properties, resulting in different areas of application for those preparations. This conclusion is only true for the normal varieties, whereas waxy starch varieties are characterized by similar pasting and rheological and texture properties. Moreover, waxy starch pastes are less altered by the presence of cosolutes, i.e., salts and sugar alcohols. This may potentially result in a wider area of application.A comparison of the studies performed on food product matrices and model binary systems showed the low usefulness of the latter in the quality design of food products. Nevertheless, starch binary systems were proven to be useful material for industrial screening tests.


Abrus precatorius (jequirity pea) is considered a biological threat agent by the Center for Disease Control and Prevention. To date, there is no effective postexposure treatment for abrin poisoning, and efforts are being made to develop an efficient vaccine and measures for postexposure therapy. Epitope mapping is widely applied as an efficient tool for discovering the antigenic moieties of toxins, thus providing invaluable information needed for the development of vaccines and therapies. Aiming to identify the immunodominant epitopes of abrin, several neutralizing antiabrin polyclonal antibodies were screened using a set of 15-mer peptides spanning the amino acid sequence of either the A or B subunits of abrin. Analysis of the antibody-binding pattern revealed 11 linear epitopes for the A subunit and 14 epitopes for the B subunit that are located on the surface of the toxin and thus accessible for antibody interactions. Moreover, the spatial location of several of these epitopes suggests they may block the galactose-binding pockets or the catalytic domain, thus neutralizing the toxin. These findings provide useful information and suggest a possible strategy for the development and design of an improved abrin-based vaccine and therapeutic antibodies.Abrin, a toxin isolated from the seeds of  Abrus precatorius (jequirity pea), belongs to the family of Type 2 ribosome inactivating glycoproteins (RIP) [Abrin, a toxin isolated from the seeds of ns (RIP) . As suchns (RIP) . Owing tns (RIP) .To date, there is no effective postexposure treatment for abrin poisoning, and efforts are made to develop an efficient vaccine and measures for postexposure therapy . InteresEpitope mapping of the polyclonal antibodies in the sera of immunized animals is widely applied as an efficient tool for discovering antigenic moieties of pathogens, and thus provides invaluable information needed for the development of vaccines and therapies . The aimAbrus precatorius seeds as described previously [Purified abrin was essentially prepared from eviously ,11. The eviously , and thaeviously . Serum RDetermination of antiabrin antibody titers was performed as described before . In shor4 cells/well) and incubated over night at 37 °C. Cell-culture medium was removed, and abrin (7 ng/mL) was added with serial dilutions of antiabrin antibodies. Twenty-four hours later, cell-culture medium was replenished with fresh medium containing proteasome inhibitor MG132  for another hour. Cells were lysed by the addition of 50 µL lysis buffer , and residual luciferase activity was determined.Determination of antibody-neutralization potency was performed as described before . In shorA set of 15 amino acid long peptides , overlapAs an initial step, we analyzed the binding properties of several polyclonal antiabrin-antibody preparations. These included ascitic fluid derived from mice immunized with purified abrin adsorbed on alum hydroxide (M1) and hyperimmune serum from rabbits immunized with abrin with Freund’s adjuvant (R1), abrin adsorbed on alum hydroxide (R2), or abrin adsorbed on alum hydroxide, followed by Freund’s incomplete adjuvant (R3).50) [50 of ~10,000 and above), the binding values of R1 and R3 were significantly higher than those of R2 and M1 (50) was determined   were det2 and M1 . Next, wtermined . OverallInterestingly, the proportion of the neutralizing antibodies in overall antiabrin antibodies  in each preparation varied by up to sevenfold (1.4 to 9.4). Different vaccination strategies using the homologous toxin ricin elicited antibodies directed against the sugar moieties of the toxin to different degrees . While aTo characterize the polyclonal antibody response toward abrin, a set of 15-mer biotinylated peptides were prepared spanning the amino acid sequence of either the A or the B subunits of abrin, each peptide overlapping with the previous peptide by 10 amino acids, thus resulting in a set of 49 and 52 peptides for ATA and ATB, respectively   that mapAs mentioned earlier, very little is known about the targets of antiabrin-neutralizing antibodies; in fact, only two such epitopes, both located on ATA, have been described so far—epitopes of antibodies D6F10 (discussed above) and A7C4 . By usinB, and thUsing the same strategy described above, the four antiabrin antibody preparations were allowed to interact with peptides spanning the amino acid sequence of the abrin B subunit (ATB). In this case, all four preparations interacted with the peptides , and 15 ATB comprises two homologous globular domains , each coVisualization of the 15 epitopes on the crystal structure of abrin revealed that all but one are located on the surface of the toxin, securing their accessibility to antibody binding B. EpitopAs the main activity of ATB is to bind galactose moieties located on the cell surface and thus mediate toxin uptake, it was of interest to examine whether any of the identified ATB epitopes play a role in abrin neutralization by blocking its ability to bind galactose. ATB contains two potential galactose-binding sites, N51 and N260, for Subdomains 1 and 2, respectively [We characterized for the first time the polyclonal antibody response towards abrin, and identified the immunodominant epitopes of each of the toxin’s subunits. By screening with antibodies derived from two animal species (rabbits and mice) by different vaccination strategies, we increased the possibility to identify a wide coverage of epitopes. It is possible, however, that these antibody preparations also target nonlinear epitopes that cannot be identified by current method applied in this study. As abrin is considered an imminent biothreat agent, there is an ongoing effort to develop effective countermeasures to this toxin. Epitope mapping of the polyclonal antibodies in the sera of immunized animals enhances our knowledge regarding the antigenic moieties of abrin and provides important information for the development of such countermeasures. Indeed, two of the identified ATA immunodominant epitopes were previously shown to be the target of neutralizing monoclonal antibodies. In the future, the neutralization potency of the novel epitopes identified in this work  will be evaluated. To conclude, the findings of this study provide useful information as part of an overall strategy to design improved vaccines and countermeasures to abrin.


Recent years have seen Moscow and Beijing driven closer together as their respective relations with Washington have deteriorated. While a normative convergence between Russia and China appears to be underway, there remains a legacy of historical mistrust in addition to potential irritants that could plague their bilateral relationship. Nonetheless, if Western sanctions against Russia and pressure on China continue unabated, they may have little option but to continue their rapprochement. Against this backdrop, this article will explore whether the two countries currently display a ‘thin’ or ‘thick’ bilateral relationship, making use of an English School theoretical framework. It will do so by exploring established English School concepts such as pluralism and solidarism and discussing notable literature within the School on contestation in order to derive conclusions regarding the potential future shape of international order in Eurasia. Recent years have seen Moscow and Beijing driven closer together as their respective relations with Washington have deteriorated Cox . Many exIn the years following the Russian annexation of Crimea, having failed to realize its initial post-Cold War vision of a ‘Greater Europe’ from Lisbon to Vladivostok, Moscow announced plans for a ‘Greater Eurasia’ instead—a supercontinent-wide integration project with Russia at its centre (Karaganov Launched in the years following the 2013–2014 Ukraine crisis, Russia’s ‘Greater Eurasia’ vision remains unformed in many ways, possibly representing an attempt to stall for time and position Moscow as an equal architect of the emerging Eurasian order Lo . NonetheThe English School of international relations is a useful tool for studying periods of change in the international order, in part due to its focus on questions surrounding the legitimacy of given norms (Stivachtis A thick or robust order comprises institutions that have a substantial effect on state behaviour in both the economic and military realms. […] A thin order, on the other hand, can take three basic forms. First, it might deal with only the economic or military domain, but not both. Even if that realm contained strong institutions, it would still be categorized as a thin order. Second, an order might deal with one or even both realms, but contain weak institutions. Third, it is possible, but unlikely, that an order will be involved with economic and military matters, but will have strong institutions in only one of those areas (Mearsheimer Whether a stark delineation between security and economic affairs should be employed as the means of separating ‘thick’ from ‘thin’ is a matter of contention and will be returned to below. What is more, Mearsheimer’s analysis reveals an exclusive focus on secondary institutions instead of primary ones. Debate over the legitimacy of certain interpretations of primary institutions—including sovereignty, the balance of power and great power management—in global international society has become an even more central feature of international politics in recent years (Allison Recent English School scholarship contends that mere mutual recognition is inherently social and that therefore there can be no distinction between ‘international system’ and ‘international society’ (Reus-Smit and Dunne  Allison . Seconda Allison . This is Allison : 98. TheHowever, the Sino-Russian relationship at the heart of the Eurasian order should be distinguished from a clearly delineated regional international society. Buzan : 22–25 dWhat is more, unlike the member states of the EU, Russia and China are great powers at the global level capable of checking the military power of the USA, having formed part of Kissinger’s famous ‘triangular diplomacy’ during the Cold War (Kofman and Connolly Recent English School scholarship has expounded on how great powers project their preferred norms onto international society in an effort to shape or defend its structure Sakwa . TherefoAlthough recent English School scholars have argued against a distinction between systemic and social politics in practice, drawing a conceptual line between the notions of ‘system’ and ‘society’ can serve as a useful analytical tool. While actors in an international system merely recognize one another’s empirical existence and are ‘fortuitous’ when a balance of power is reached, when the level of a pluralist international society is attained they develop norms such as respect for one another’s sovereignty and establish an equilibrium that is ‘contrived’, thus rendering pluralism ‘a qualified progressivist interpretation of world politics […] in which states move beyond purely strategic forms of interaction’ (Linklater and Suganami Moreover, the states spread by European powers across the globe took the form of those developed in the nineteenth century rather than the early modern period, by which point European international society’s pluralist foundations had already been placed under stress by the advent of nationalism, thus generating a link between pluralism and solidarism Buzan : 97–112.Exhibiting somewhat of a parallel with more recent English School scholars, Watson : 318 conEnglish School scholars also disagree on the nature and effect of contestation. Bozeman : 405 conDespite instances of agreement, the above analysis confirms that competing views exist within the English School regarding the extent to which normative divergence impedes the potential for thickness. While Little : 22–26 cFollowing the onset of the Ukraine crisis in 2014, Moscow accelerated its previously declared ‘pivot to the east’ (Bolt and Cross Moscow and Beijing’s nominally joint commitment to the principle of non-interference in the internal affairs of sovereign states is not always evident in practice, with Russia notably having violated the territorial integrity of Georgia, Moldova and Ukraine while also meddling in Western elections. That said, both sides have implicitly recognized the notion of spheres of influence, with Beijing deferring to Russian interests in Eastern Europe and the Middle East and Moscow acknowledging Chinese pre-eminence in East Asia Lukin , furtherAgainst this backdrop lies the perennial question of Russia’s great power status and the recurring theme of its desire to be treated as an ‘equal’ Liik . Russia The question of Russia’s great power status can be thought of as relating to the traditional primary institutions of great power management and the balance of power. Therefore, if Russia and China prove unable to agree on the nature and implications of Moscow’s status as a great power in Eurasian and global affairs, then this may preclude the long-term entrenchment of a thick relationship between them. Lo  contendsCooley : 70 contWhile Russia has grown increasingly dependent on China, the reverse has also become true as USA–China relations have grown fraught in recent years Lukin . The neeWhen it comes to the wider Eurasian region, Moscow and Beijing have notable foreign policy differences, including, for example, Russia’s desire to diversify its partnerships and maintain good relations with Vietnam despite the latter’s rivalry with China in the context of the South China Sea (Bolt and Cross Beyond bilateral ties, Russia–China cooperation often boils down to reactions to emerging crises, such as those in Syria, on the Korean Peninsula or in Venezuela. The two countries do their best to counter the attempts of the United States to undermine the sovereignty of independent countries, apply double standards to global politics, and use sanctions and trade wars. […] Russia and China often use the same terms to describe the future they desire: multipolarity, a post-Western world, the indispensability of the rule of law, the indivisibility of security, and so on. Sadly, however, most of these terms remain predominantly proclamatory; there is no concrete meaning to them. If you dissect any of these notions with the sharp scalpel of a depoliticized analysis, you will find numerous latent contradictions, internal conflicts, and incongruities Kortunov .While deeper engagement across the Asia–Pacific region could be a sign of a more developed and refined ‘pivot to the east’, a convergence with China remains in line with the traditional Russian foreign policy aim of counterbalancing American hegemony and the Western-led liberal international order (Lo Yet despite the genuine normative convergence that has developed between Russia and China, it is largely centred around broad principles rather than specifics. Kortunov elaborates on this issue, writing:order Lo . This isorder Lo , suggestorder Lo  notes thorder Lo . Russia,order Lo .The ‘porous’ nature of the EAEU, having failed to ‘complete the implementation’ of its rules and norms, has allowed China’s economic presence in Central Asia to proceed largely unimpeded, thus tempering the likelihood of both powers’ key regional interests clashing (Kaczmarski The above analysis suggests that while certain elements of the Sino-Russian partnership remain instrumental or underdeveloped, there nonetheless remains a relationship between them rooted in nominally shared norms. The return of great power rivalry at the global level has strengthened the rapprochement between the two powers, while the potential for clashing interests and identities at the regional level is less extensive than often assumed. This suggests that fundamental contestation of a normative nature between Moscow and Beijing is unlikely to occur as an impediment to the construction of a thick relationship between them, even if the former occasionally emphasizes the multi-vectored and independent nature of its foreign policy (Petersson First is the importance of norms in the English School tradition. While it is possible that both Russia and China have been brought together in large part due to their shared opposition to the excesses of American and Western hegemony, the normative facets of their bilateral relationship could take on a life of their own. A shared set of norms and understandings rooted in a broadly similar conception of global and regional order could become entrenched. For example, Sakwa : 42 noteSecond, although Russia’s ‘pivot to the east’ is in large part associated with a desire to balance against Western hegemony, this does not necessarily imply that sustained and deeper interaction with Eurasia and the Asia–Pacific have not become increasingly meaningful to Russia in their own right. Moreover, if the Sino-Russian relationship remains rooted in the principle of mutual respect and non-interference, then Russia’s insistence on being accorded great power status will not necessarily inhibit their ability to cooperate effectively. To a certain extent, then, the question is not whether Russia remains preoccupied with being accorded great power status, but rather how it chooses to interpret that status. Instead of pushing for an entrenched sphere of influence and promoting a Yalta-type order Popescu , it coulFinally, it is possible at first glance to contend that Russia and China possess different conceptions of international order. Russia, having been relegated to second-tier status in the post-Cold War order, privileges a polycentric conception of order and takes direct aim at the notion of Western leadership, whereas China is more preoccupied with preserving the international conditions conducive to it continuing its economic development and modernization since it has largely benefitted from the international status quo Kofman . Howeverorder rather than international society. Moscow’s preoccupation with defending the autonomy of global international society from perceived Western transgressions (Sakwa society. In other words, the precise configuration that the international order takes matters less to Beijing than the need simply to preserve the international conditions necessary for it to complete its national economic and development-related goals (Deng Russia has been a participant European international society for several centuries.ns Sakwa : 47 can ns Sakwa . By contals Deng : 66. FarThe nature of the Sino-Russian partnership is such that they ‘stay away from contesting each other’s core interests or supporting adversaries in key contests’ Kofman , even ifThe level of shared norms and identity between Moscow and Beijing—beyond anti-hegemonism and authoritarianism—may remain somewhat limited. Moreover, it is possible that identity-related developments in both countries, including but not limited to rising nationalism, could drive them apart over the medium-to-long term despite their current normative rapprochement Rozman : 267–277The possibility of viewing the Sino-Russian relationship as ‘thick’ from an English School perspective contrasts with more established views. The conception of thin and thick orders advanced by Mearsheimer  would po12


The purpose of this study was to determine the effect of the weave technique for hamstring graft preparation on the diameter of the prepared graft, functional outcome, and need for harvesting of semitendinosus and gracilis (ST + G) or semitendinosus alone (ST).This retrospective study evaluated 340 patients who underwent arthroscopic anterior cruciate ligament (ACL) reconstruction from January 2013 to December 2015. Our protocol for graft preparation is that the graft length must be a minimum of 8 cm and the diameter must be between 7 and 10 mm. The parallel-graft preparation technique was used in 189 patient and the weave technique was used in 151 patients. Outcome was measured by using stress radiographs and International Knee Documentation Committee (IKDC) 2000 score.p < 0.0001). There was no statistically significant difference at 2 years of follow-up in stress laxiometry, IKDC 2000 scores and rerupture rates between the two groups.In the parallel-graft preparation group, ST + G was used in 99 patients and ST was used in 90 patients. In the weave-graft preparation group, ST + G was used in 38 patients and ST alone was sufficient in 113 patients. The need for G harvest was less in the weave-technique group (The weave technique helps to reduce the need for G harvest without compromising functional outcome.Level of evidence IV. Reconstruction of the anterior cruciate ligament (ACL) is recommended for the prevention of instability, further intra-articular disease, and recurrent injury in the ACL-deficient knee . BecauseBiomechanical studies using animal tendons to determine the effect of braiding or twisting on initial graft strength and stiffness have not yielded clear conclusions. A study done by Kim et al. on human tendons show that twisting and braiding reduces the tensile strength and stiffness of human hamstring tendon grafts used for ACL reconstruction . HoweverThe purpose of this study was to determine the effect of the weave technique for hamstring graft preparation on the diameter of the prepared graft, the need for harvesting of ST and G or ST alone, and functional outcome. Our hypothesis is that the weave technique and parallel-graft technique do not affect the final graft diameter and the need for harvesting of the G tendon.After obtaining Ethical Committee approval, we retrospectively evaluated 340 patients who underwent arthroscopic ACL reconstruction from January 2013 to December 2015. Out of these, 189 patients were treated using the parallel-graft technique and 151 patients using the weave technique. ACL reconstructions before October 2014 were done using the parallel-graft preparation technique and thereafter the weave-graft preparation method was used. For ACL reconstruction, hamstring graft tendons  were used. For graft preparation, we followed the protocol of our institution: the graft length must be a minimum of 8 cm and the diameter must be between 7 and 10 mm. In patients who had a graft diameter less than 7 mm after preparation by either method, we harvested the G. We excluded patients who had a partial ACL tear or a meniscal tear (grade 3), underwent double-bundle ACL reconstruction, in whom an allograft was used or any method of fixation used other than aperture fixation, and who had multi-ligamentous injury.° of knee flexion, and posterior drawer test. After applying a tourniquet, the operated part was cleaned and draped. A diagnostic arthroscopy was performed using standard anterolateral and anteromedial portals.Under spinal or epidural or general anesthesia, the knee is examined for ligament injury using Lachman’s test, the anterior drawer test, pivot shift test, valgus and varus stress test in full extension and in 30Hamstring tendons are identified at an average of 2 cm distal to the joint line and 2 cm medial to the tibial tubercle. A longitudinal incision over the anteromedial tibia is made, and dissection is carried through the subcutaneous tissue till the sartorius fascia is reached. The fascia is palpated to identify the underlying ST and G tendons. The tendons are blend together at their insertion site on the tibia and the interval between them is more distinct proximally and posteriorly. The sartorius fascia is then incised over this interval in the line of tendons. A right-angle clamp is used to isolate the tendons. After the vincular attachments are cut under visual control, the ST and G tendons are harvested with a closed-type tendon stripper.After harvesting ST + G or ST tendons, attached soft tissue is removed with the non-cutting side of a surgical knife. The length of the harvested graft is measured and is usually about 240 mm for the ST. In the parallel-graft preparation method, one end of the graft  is sutured with a 1–0 vicryl suture and fixed to a clamp (C1) on the graft preparation platform, the graft is bent at about 80 mm and secured to another clamp (C2) with a 1–0 vicryl suture. Another 80 mm of the graft  is bent again at C1 and fixed to C2 after pretensioning and stitched with a 1–0 vicryl suture. Graft diameter should be between 7 and 10 mm. So if it is required to increase the diameter, the G tendon is also harvested and prepared over the earlier graft in a similar manner. This forms the quadrupled or pentavalent hamstring tendon graft. In the weave technique, the initial part of graft preparation is the same. The two thirds of the graft are bent in a similar fashion and clamped to the two respective clamps as stated earlier. These are parallel. Now the remaining third (80 mm) is woven over these two parallel strands and stitched to clamp C2 after pretensioning Figs. . If the An accessory anteromedial portal is used for femoral tunnel preparation in more than 100° knee flexion. The graft is fixed with aperture fixation (tunnel mouth fixation/interference screw) using screws (titanium or biodegradable).Patients were given intravenously administered antibiotics for 1–2 days postoperatively. Ankle and foot movements, static quadriceps exercises, knee range of motion, and straight leg raising were started as soon as the patients recovered from anesthesia. Mobilization walking with walker support was started the next day with priority focussed on the recovery of full extension. Wound inspection was done on the second postoperative day and patients were discharged with orally administered antibiotics and analgesics for 5 days. Stitch removal was performed 10 days postoperatively. All patients underwent the same rehabilitation program till they achieved a full range of motion at the knee joint and 5/5 power for quadriceps and hamstrings.Follow-up was done at the time of stitch removal and 6 months and 2 years postoperatively. Patients who were lost to follow-up were excluded from the study. Only those patients who completed full rehabilitation were included in the study. Outcome was measured by using the International Knee Documentation Committee (IKDC) 2000 score (subjective), radiographic stress laxiometry (objective), and rerupture rate of the reconstructed ACL. In stress radiography, the lateral view of the knee joint at 90° of flexion was taken by applying the anterior drawer stress simultaneously (as the anterior drawer test is routinely done at 90° of flexion). Anterior tibial translation was then measured in millimeters on these radiographs. Flexor strength was checked clinically preoperatively and periodically postoperatively by asking the patient to perform prone knee bending with a strap weight attached just proximal to the ankle (maximum load and standard set of 30 repetitions).t test and a p value of less than 0.05 was considered significant.The data were analysed by software MEDCALC. Group comparisons were done using a p value came out to be highly significant (p < 0.0001), showing that the ST tendon alone is enough when using the weave technique to achieve the required graft diameter. Hamstring strength, measured by using prone knee bending, was initially better in patients in whom the G was preserved but both groups were able to lift a similar weight (8–10 kg) at the end of the rehabilitation program at 6 months after surgery. On radiographic laxiometry (anterior), performed immediately postoperatively and at 6 months after complete rehabilitation, the difference was insignificant between the two groups. It was between 2 and 4 mm for both the groups with average being 2.5 mm in both groups. Subjectively, at 2-year follow-up, there was no difference between the two groups in terms of functional outcome that was measured using IKDC 2000 . The rerupture rate of the reconstructed ACL was higher in the parallel-strand graft  compared to the weave graft  at the end of the 2-year follow-up, but the difference was not statistically insignificant   tendon graft, even after a full rehabilitation protocol was followed . Ardern Yosmaoglu and Baltaci compared the results of a multi-joint, lower-limb, tracking-trajectory test, the peak torque of knee extensors and flexors at 60/s and 1800/s, and anterior tibial translation in patients who received ST and STGR grafts at 12 months after ACL reconstruction. They found that the side-to-side differences in flexor peak torque at 600/s were significantly higher in the STGR group than in the ST group. The side-to-side differences in extensor peak torque did not significantly differ, suggesting that preservation of the GR might improve postoperative athletic function .The ST and G muscles also contribute to internal shin rotation; thus, it has been suggested that harvest of these tendons can result in internal shin-rotation weakness. Although the G is not truly a hamstring muscle it is considered to be a muscle of the medial compartment of the thigh which flexes and medially rotates the shin at the knee. Interestingly, Ahlen and Liden, evaluating a group of patients with a mean time since ACL reconstruction (STGR) of 8.5 years, demonstrated significant side-to-side differences in flexion peak torque but no significant peak torque deficit in internal shin rotation. Because of significant weakness in deep knee flexion, the authors suggested avoiding STGR autografts for athletes who depend on strength in deep flexion . The posShort follow-up is one of the limitations of this study; another one is that the time period of the techniques was quite different. Future studies involving a longer follow-up and objective measurement of the maximum strength of human autografts prepared in either way are required.The weave technique for hamstring graft preparation in ACL reconstruction is a good alternative to the conventional parallel-strand technique using aperture fixation. The weave technique helps to reduce the need for G harvest without compromising the diameter of the graft, final functional outcome, and stability.


Persistent left superior vena cava is a not uncommon congenital vascular abnormality. We report a case of heart transplantation with reconstruction of persistent left superior vena cava using a prosthetic vascular graft.A 20-year-old man with idiopathic dilated cardiomyopathy and persistent left superior vena cava underwent orthotopic heart transplantation 2 years and 3 months after left ventricular assist device implantation. Because the persistent left superior vena cava had a larger diameter than the right superior vena cava, the transected persistent left superior vena cava was reconstructed with a prosthetic vascular graft anastomosed to the free wall of the right atrium. Postoperative enhanced computed tomography revealed good patency of the graft. The patient’s postoperative course has been uneventful during 2 years of follow-up, despite the risk of complications.Reconstruction of a persistent left superior vena cava with a prosthetic vascular graft may be one option at the time of heart transplantation. Persistent left superior vena cava (PLSVC) is a not an uncommon congenital vascular abnormality  . Prior cA 20-year-old man diagnosed with idiopathic dilated cardiomyopathy presented with deteriorated cardiac function (left ventricular (LV) ejection fraction 18%). After registration with the Japan Organ Transplant network, he underwent continuous-flow LV assist device (LVAD) implantation as a bridge to transplantation. When a donor in good condition was found 2 years and 3 months after LVAD implantation, we decided to perform heart transplantation. The PLSVC and atresia of the left brachiocephalic vein (LBCV) were recognized on preoperative chest computed tomography  in side-to-end fashion Fig. . The posThere are various types of PLSVC. In 92% of patients, the PLSVC connects to the RA via the coronary sinus (CS) and 65% of patients have an absent LBCV [There are various opinions concerning the best way to deal with PLSVC in heart transplantation, depending on the type of PLSVC. In transplant patients with a right SVC and LBCV of adequate size, simple ligation of the PLSVC is acceptable . If the In our patient, we initially planned to ligate the PLSVC because the right SVC seemed to be larger than the PLSVC. We deemed PLSVC ligation a safe procedure because the innominate vein is sometimes simply ligated and divided to improve access  without postoperative left upper limb swelling or neurological symptoms . The metAcute thrombosis and occlusion of the vascular graft is one of the possible postoperative complications and may cause symptoms of acute venostasis. Fortunately, this complication was not observed because we used warfarin to maintain our patient’s international normalized ratio of prothrombin time at 1.5 to 2.0. Postoperative enhanced computed tomography revealed good patency of the reconstructed graft, and the patient had experienced no venostasis symptoms.Thrombotic occlusion of a prosthetic graft anastomosed to the venous system often occurs, regardless of graft size. However, several studies reported that severe complications, such as pulmonary embolism, were rarely observed –11. AlthProsthetic graft infection is another possible adverse event because patients must take immunosuppressive agents after heart transplantation. Although our patient has had no episodes of infection to date, careful follow-up will continue to be necessary.The advantages of PLSVC reconstruction with a prosthetic vascular graft are that there is no need to change the operative technique on either the donor or recipient side and the procedure is easy to perform. In this case, we did consider anatomical bypass to the right SVC. However, unfortunately, the PLSVC was located behind the left pulmonary artery and in front of the left pulmonary vein. In this situation, we were afraid of graft kinking and/or compression of the pulmonary artery and right ventricle if the reconstructed graft was routed in front of the heart. Therefore, we chose posterior routing as an alternative path. To be sure, the posterior routing risked compression of the pulmonary vein and also had a risk of graft compression by the heart. Therefore, we first anastomosed the ringed graft to the edge of the PLSVC. Then, we checked the graft configuration, including surrounding tissue, and decided to pass the graft posterior to the heart to avoid graft kinking and compression of the pulmonary artery and right ventricle. We thought that anastomosing the graft to the RA free-wall would be easy. Then, we confirmed adequate blood flow through the PLSVC, adjusted the length of the graft posterior to the heart, and performed end-to-side anastomosis. If we had selected anterior graft routing, a longer prosthetic graft would have been needed to avoid heart compression. Another concern is that adhesions around the LV resulting from the prosthetic vascular graft may induce LV diastolic dysfunction. In our patient, follow-up echocardiography 2 years after transplantation showed good systolic and diastolic function of the transplanted heart. However, careful monitoring of cardiac function will be necessary hereafter.We successfully performed heart transplantation with PLSVC reconstruction using a prosthetic vascular graft. We were deeply concerned about the risk of complications. However, the patient’s postoperative course has been uneventful 2 years after the surgery, without any venostasis-related symptoms, infections, or diastolic dysfunction. Although careful observation is mandatory, reconstruction of the PLSVC with a prosthetic vascular graft is one option in heart transplantation.


Opioid Maintenance Treatment (OMT) is a well-evaluated treatment of opioid use disorder (OUD). Especially, under the condition of imprisonment, OMT is a preventive measure regarding infectious diseases such as hepatitis C. However, only a minority of prisoners with OUD are currently in OMT in numerous countries. In 2009, the Ministry of Justice of the federal state of North Rhine-Westphalia (NRW), Germany, launched the process of implementing OMT in prisons with various elements . In the recommendations OMT was defined as the gold standard of treatment of OUD.To assess the effectiveness of the implementation strategy a survey on the prevalence of OMT in prisons in NRW was carried out twice a year by the Ministry of Justice between 2008 and 2016. Participants were prisoners in NRW, Germany. The diagnosis of OUD at admission to prison and the treatment state on survey dates was measured.The number of prisoners in NRW dropped from 17,301 in 2008 to 16,432 in 2016. In the same period, the number of prisoners with OUD  dropped from 4201 persons to 3650 persons and the number of prisoners in OMT increased from 139 persons (3.3%) to 1415 (38.7%) persons.Currently, the percentage of prisoners with OUD in OMT in NRW is almost reaching the treatment rate outside prisons in Germany (45–50%). However, after release from prison there is still a high risk for a discontinuation of OMT.Overall, the top-down approach of implementing OMT in prisons in the federal state of NRW was effective. Substance use disorder is one of the leading problems in the international field of health-care . An estiAccording to current concepts, OUD is a disorder with a chronic course . AbstineMany prisoners suffer from OUD and compared to the community, people, who use drugs are even over-represented in prisons . AccordiThe World Health Organization recommends OMT in prisons as standard treatment . In GermNorth Rhine-Westphalia (NRW) is the most populous federal state of Germany with about 18 million inhabitants. Given the low rate of OMT in German prisons, the Ministry of Justice of the federal state NRW launched the process of implementation in 2009. It has several elements:Development of recommendations for the treatment of prisoners with OUD: The recommendations were developed by a task force consisting of representatives of the boards of physicians of North Rhine and of Westphalia, respectively, directors of prison hospitals in NRW, prison doctors, and representatives of the Ministry of Justice NRW. The development of the recommendations was based on the guidelines of the German Board of Physicians , which eEducation: As a specific medical qualification is required in Germany to carry out OMT (“Suchtmedizinische Grundversorgung” meaning “basic care for substance use disorders”), prison doctors were asked by the Ministry of Justice to achieve this qualification by completing a course of 50 h. In addition, the recommendations were presented and discussed at a mandatory workshop for all prison doctors in 2010.Monitoring: In principle, physicians in the community and in prisons are free in the choice of a treatment for an individual patient in Germany. In consequence, there are no directions of the Ministry of Justice or the prison directors to prison doctors how to treat an individual prisoner. Therefore, after the announcement of the recommendations there was no routine ministerial check at the level of individual prisoners with OUD, why they do not receive OMT. Rather a monitoring by the Ministry of Justice was established regarding the number of prisoners with OUD and the number of prisoners in OMT. These figures had to be reported by each prison twice yearly. In this way, the rate of prisoners in OMT was regarded as a criterion for the quality of care for people with OUD in a given prison. The data were presented and discussed at the mandatory meetings of prison doctors organized by the Ministry of Justice once yearly.As the recommendations evaluate OMT as the gold standard of the treatment of OUD, there is a lack of quality of care if only single individuals with OUD in a prison are in OMT. This evaluation does not interfere with the right of physicians to state the indication for OMT for an individual person. In addition, after the announcement of the recommendations the prison doctor could be asked in case that an individual prisoner complains about not receiving OMT, why he did not carry out the gold standard treatment in this case.The aim of this study is to assess the effectiveness of the implementation strategy for OMT in prison. We hypothesized that the number of prisoners with OUD in OMT would increase during the monitored period.In the federal state of NRW, Germany, there are 62 prisons with up to 18,500 prisoners located. In order to assess the effect of the described implementation process (and as part of this process), a survey was carried out twice a year (April and October) over the years of 2008–2016. The survey gathered data on the number of prisoners at the respective dates over all prisons in NRW, the number of prisoners with OUD, and the number of prisoners currently in OMT (methadone or buprenorphine). The twice-yearly report was carried out by different staff members of the participating prisons, e.g. prison doctors, social workers, or other professionals of the medical service. Data were centrally gathered and analysed at the Ministry of Justice NRW. The respective prison doctor diagnosed OUD based on a diagnostic interview held at the admission to prison. In Germany, OUD is diagnosed according to the diagnostic criteria of the ICD-10. In addition, a drug urine screen was carried out in order to detect use of heroin and of other substances . Since 2017, a nationwide survey on OMT in prisons in Germany has been established which replaces the former survey just in NRW with slightly different methods.As a part of OMT in prison, psychosocial interventions are offered. These differ between the participating prisons. However, every institution provides counselling for OUD, where prisoners can obtain information or advice if required.2  = 69.84, p < .01. At the respective dates, the number of prisoners with OUD also decreased significantly from 4201 in 2008 to 3650 in 2016  = 38.67, p < .01). In the period from 2008 to 2016, the number of prisoners in OMT increased from 139 persons out of 4201 prisoners with OUD (OMT rate: 3.3%) to 1415 out of 3650 prisoners with OUD (OMT rate: 38.8%). In 2017 the number of prisoners in OMT increased even further to 1603  = 168.87, p = <.01.The number of prisoners in NRW dropped from 17,301 (in 2008) to 15,781 (in 2017) at the qualifying dates for the survey. There were statistically significantly fewer prisoners in 2017 compared to 2008. A chi-square test of goodness of fit was performed to determine whether the number of prisoners was equally distributed between the years. The number of prisoners was not equally distributed, χPrisoners with OUD were mainly male [in 2016: 3350 males (91.8%) and 300 females (8.2%)]. The proportion of male prisoners in OMT increased over the years from 11.4% in 2010 to 37.0% in 2016  is almost reaching the treatment rate (about 45–50%) in the community in Germany. The effectiveness of the implementation process is based on several elements: the clear statement of the Ministry of Justice that OMT has to be implemented in prisons, treatment recommendations developed by the medical profession defining a standard of care, medical education of prison doctors regarding substance use disorders, and a monitoring system about the implementation of OMT.Furthermore, the number of prisoners in NRW dropped from 17,301 to 15,781 on the qualifying survey dates. At the same time, the number of prisoners with OUD decreased from 4201 to 3650. An explanation for a reduction of prisoners with OUD in the studied time period might be a reduction of heroin-related offences in Germany. The overall number of drug-related offences increased from 231,007 in 2010 to 352,320 in 2018, whereas drug-related offences with relation to heroin decreased from 24,574 in 2010 to 11,402 in 2018. Since drug offences are among the main offences of people with OUD, this might be a partial explanation for a reduction of prisoners with OUD . The numFurthermore, in 2012, the Federal Cabinet adopted the National Strategy on Drug and Addiction Policy in Germany. The strategy aims to help individuals avoid or reduce the consumption of substances and is based on prevention, treatment, harm reduction measures, and repression . The adoWe also found a difference between male and female prisoners in OMT. The proportion of male prisoners in OMT increased over the years from 11.4 to 37.0%. The proportion of female prisoners in OMT was already relatively high in 2010 with 37.2% and remained rather stable during the following observation period.A nationwide survey in German prisons found that female prisoners use opioids more often than male prisoners and that 34% of female prisoners had OUD compared to 19% of male prisoners . FurtherDespite the effectiveness of the process of implementation, the majority of prisoners with OUD in NRW are still not in OMT. However, about half of the people with OUD in the community are also not in OMT in Germany. There may be different reasons for patients staying out of OMT. Firstly, OMT is a difficult choice for patients, who might fear treatment rules , 33: DruMoreover, the role of stigmatization for the implementation of OMT in prison should be emphasized. Even though OMT has been officially accepted as the gold standard treatment of OUD, it continues to be stigmatized. 78% of a study sample of patients currently in OMT reported having experienced stigma related to OMT . Some peEven though the number of prisoners in OMT increased during the last years in NRW, there is the problem of continuity of OMT. This might regard the continuation of OMT at admission to prison as well as upon prison release. Besides the fact that an abrupt ending of OMT at imprisonment clearly offends against the legal principle of equivalence, this can be physically and psychologically distressing for the imprisoned patients  and evenThe following limitation of the study has to be discussed: The diagnosis of OUD is based on the diagnostic interview carried out by the prison doctor at admission of a prisoner to the prison. In addition, a drug urine screen is carried out in order to detect use of heroin and of other drugs. As the diagnostic criteria of OUD are mainly based on information given by the prisoner there might the risk of underdiagnosing OUD. However, the rates of prisoners with OUD out of all prisoners in NRW are within the range known from other federal countries in Germany . In addiOverall, our work has led us to conclude that the top-down approach of implementing OMT in prisons in the federal state of NRW was effective. It seems that the clear statement of the Ministry of Justice that OMT has to be implemented in prisons as well as treatment recommendations developed by the medical profession defining a standard of care, medical education of prison doctors and a monitoring system were important parts in increasing the amount of prisoners in OMT. The percentage of prisoners with OUD in OMT in NRW has increased continuously since 2009 and is now almost reaching the treatment rate in the community in Germany. Nevertheless, the majority of prisoners with OUD are not in OMT. Reasons for staying out of OMT might be fear of treatment rules, negative experiences with treatment or stigmatization. Furthermore, there is still a high risk of a discontinuity of OMT at admission to prison as well as upon prison release. Future research needs to focus on effective ways to ensure a consistent continuation of treatment in terms of the principle of equivalence.


Gastroenterology is the branch of medicine focused on the digestive system and its disorders and broadly includes gastrointestinal (GI) and liver diseases, GI endoscopy, and surgery. The first practitioners of gastroenterology were surgeons. At the turn of the 19th century, surgeons were at the forefront of the treatment of a very common GI disease at that time—peptic ulcer disease.Gastroenterology developed rapidly as a special field with the advent of fiberoptic endoscopy in the early 1960s. Accurate diagnoses of diseases of the GI tract could then be made with endoscopy. Reflux esophagitis and peptic ulcer disease could be diagnosed with certainty by direct visualization of the pathology. Soon, many endoscopic procedures were performed, and the specialty of gastroenterology started to develop.In many countries across the world, surgeons started performing endoscopy as part of their clinical practice, but soon, general physicians with a special interest in gastroenterology became more adept and focused at endoscopy than surgeons. As they started to spend more time in gastroenterology and GI endoscopy, the fraternity of gastroenterologists began to be established. Liver diseases were also in their domain. However, with the discovery of the hepatitis viruses and the great advances in the laboratory science of liver diseases, hepatology as a subspecialty started to evolve separately. GI endoscopy had also become more sophisticated, and endoscopists soon had to develop special skills to perform more difficult procedures such as endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic resection of early cancers. GI endoscopy has also now evolved into a separate field.In February 1960, at a meeting in Tokyo, the legendary Henry Bockus of the United States of America, President of the International Society of Gastroenterology or Organisation Mondial de Gastro‐Enterologie (OMGE), had suggested to Dr. Shin‘ichi Kawashima, President of the Japan Society of Gastroenterology, to form an Asian Society of Gastroenterology. The Japan Society had already been in existence for many years! Dr Kawashima gathered his colleagues and friends from across the Asian Pacific region, including Dr Vikrit Viranuvatti of Thailand , similar to that of the highly successful Digestive Disease Week of the United States. SK was truly the Asian Pacific leader in gastroenterology at that time. A pro tem committee was set up, including members from sister organizations ‐ the Asian Pacific Study for Liver Disease (APASL) and the A‐PSDE. SK also invited the International Society for Digestive Surgery Asia‐Pacific (ISD‐AP) to join the group, and together, the APDW was born. The group was essentially a “steering committee” with SK Lam as the founding chairman. The APAGE secretariat served as the pro tem secretariat for the group, although the services of a professional congress organizer, “The Meetings Labs” from Singapore, was enlisted to run the “day‐to‐day” work of the committee.The first APDW was held in 2001 in Sydney under the leadership of Professor Geoff Farrell, who was also at that time the President of the Gastroenterological Society of Australia (GESA). It was a wonderful inaugural meeting held in beautiful new facilities at the Darling Harbour Complex in Sydney. The success, was in no small measure, a reflection of the personal effort and commitment of Geoff Farrell in pushing for a unified Asian Pacific meeting. Subsequently, the meetings were held yearly, rotating between several cities in the region  took over as president from 2014 to 2018. Kentaro Sugano (Tochigi) is the current President of the APDWF until 2020. The APDWs have evolved to be very popular and successful meetings. The flexibility given to the local host committee each year to organize the meeting in their respective home cities in the Asian Pacific region has given an interesting diversity and flavor to the meetings while maintaining the high scientific standards that have been set in place by the APDWF.Journal of Gastroenterology and Hepatology (JGH) were Shiu‐Kum Lam, Hong Kong; Kunio Okuda, Chiba; Lawrie W Powell, Brisbane; and David JC Shearman, Adelaide, and the first issue was published in 1986.JGH.In 1984, Mark Robertson, Senior Publishing Manager of Blackwell Science based in Australia, first mooted the idea of an Asian Pacific journal dedicated to gastroenterology and hepatology. This provided the impetus to bring together key leaders in the field of gastroenterology. The founding editors of the Kunio Okuda was the inaugural Editor‐in‐Chief, followed by SK Lam Fig. . The jouHowever, more importantly, the journal brought together a group of senior leaders in the field to cooperate and start meaningful dialogues in collaborative research and in streamlining clinical care across the region. Aside from the principal task of publishing the journal, the editors were, in reality, the leaders of the GI fraternity in the Asian Pacific region and fulfilled an unofficial but important task of weaving together the whole GI community in the region.JGH  in 2002. The senior editors at that time decided that the money from the Foundation should be used for the advancement of medicine, medical research and education, and training in the fields of gastroenterology and hepatology within the Asia Pacific region. Its overall aim is to enhance the quality of medical practice and the health of the communities concerned. The trust, the Journal of Gastroenterology and Hepatology Foundation (JGHF), was originally set in place as a result of a profit‐sharing agreement between the founding editors and the publisher.JGHF is registered in Australia as a “company limited by guarantee.” Its nine trustees are drawn from current and past editors of the Journal who serve 3‐year terms that can be renewed for up to a maximum of 9 years. Geoff Farrell was the inaugural chairman from 2002 to 2008. He was followed by Neville Yeoman  from 2008 to 2012 and KL Goh  from 2012 to 2016. From 2016, the Foundation has been in the reliable hands of chairman Ian Roberts Thomson, emeritus professor at University of Adelaide.Geoff Farrell was editor of the journal from 1991 to 1998. In 2006, he returned to the journal as Editor‐in‐Chief of the JGH Fig. , a positJGHF contributes directly to the APDW by fully sponsoring the two main lectures of the meetings, the Warren and Marshall Lecture and the Okuda lecture, as well as two Emerging Leaders lectures. The JGHF also collaborates with the APDWF in sponsoring travel grants for young researchers and clinicians to attend the APDW. From 2015, under the leadership of Professor Rakesh Aggarwal (Lucknow), the JGHF fully sponsors an exciting 1‐day pre‐congress Young Clinician/Investigator course during the APDW.The JGHF shares with the APAGE a young Clinician/Scientist Award that was started by Neville Yeomans in 2005 when he was Chairman of the APAGE Awards committee. The JGHF also funds numerous projects across the AP region, including symposiums, for example, on celiac disease and FODMAPs and consensus meetings on gastroesophageal reflux diseases, Helicobacter pylori infection, and gastric cancer.In addition, the JGH Open was inaugurated in 2017 with the first issue being published in September 2017 with KL Goh as the Founding Editor. Initially, it was published monthly, but by 2018, it was switched to a two‐monthly publication schedule. The establishment of the JGH Open is in response to the rapidly changing landscape of publishing throughout the world. There are now fewer journals in print but many journals that are published solely online. This saves costs but also expedite publications of articles with free or open access of articles; it is a great boon to researchers and readers. However, the main drawback, at least facing the majority of AP countries, is the article processing charge (APC). Authors and institutions and governments will have to adapt quickly to this change as it is predicted that, by 2025, the majority of major journals across the scientific fields will be published as open access journals. This will be the new norm for journals! For a fledgling journal without an impact factor (IF) and without yet an established profile, this will pose a great challenge in the coming years.The JGH loyally for 6 years, the JGH, in January 2018, appointed a new editor, Joseph Sung from Hong Kong. Joseph, who had recently retired from the position of President and Vice‐Chancellor of the Chinese University of Hong Kong, brings a new spirit of energy and dynamism to the journal with many new and innovative ideas.The world of medical publishing has become very competitive. With the retirement of Mamoru Watanabe (Tokyo) in 2017, who had served the JGH and JGHF are Asian Pacific icons. Their contribution goes beyond publishing articles. Their far‐reaching influence and respectability, established over the years, will mean that they will continue to play a major role in Asian Pacific gastroenterology for many years to come.The


I read with great interest the manuscript entitled "Association between sexual activity during menstruationand endometriosis: a case-control study" published inthe International Journal of Fertility and Sterility .Accordi