International Journal of Telerehabilitation (IJT) is a biannual journal dedicated to advancing telerehabilitation by disseminating information about current research and practices. This open-source journal is indexed by PubMed and Scopus. IJT requires no readership or author fees.The international authorship. In the current issue, we are very pleased to publish work by authors from Australia, Chile, India, Italy, Hong Kong, and Saudi Arabia, in addition to articles from the United States.IJT enjoys a diverse international readership. Since its inception in 2008, approximately half of the journal's readership is from the United States. The journal's audience (in order of frequency) also includes readers from: Australia, India, Philippines, United Kingdom, Canada, Brazil, Italy, China, Spain, Germany, Singapore, France, South Korea, Turkey, Hong Kong, Ireland, Iran, Saudi Arabia, Chile, Netherlands, Malaysia, Finland, Indonesia, Columbia, Portugal, South Africa, Japan, Greece, Israel, Taiwan, Belgium, Thailand, Pakistan, Denmark, New Zealand, Austria, Poland, Sweden, Nigeria, Mexico, United Arab Emirates, Argentina, Switzerland, Peru, Norway, Russia, Puerto Rico, Oman, Egypt, Croatia, Czechia, Latvia, Romania, Kenya, Lithuania, Slovenia, Lebanon, Cyprus, Ukraine, Kuwait, Bangladesh, Jordan, Qatar, Estonia, Ghana, Bulgaria, Sri Lanka, Hungary, Iceland, Ecuador, Vietnam, Serbia, Bahrain, Malta, Uganda, Iraq, Bosnia and Herzegovina, Nepal, Tanzania, Guam, Palestine, Algeria, Morocco, Trinidad and Tobago, Georgia, Venezuela, Costa Rico, Ethiopia, Jamaica, Brunei, Cambodia, Bolivia, Maldives, Zimbabwe, Macao, North Macedonia, and Panama.IJT also enjoys a wide IJT does not actively engage in marketing. We surmise that this wide readership is testimony to the expanding global relevance of telemedicine, telehealth, and telerehabilitation.Such a diverse international audience would not be likely without the journal's use of an open journal system (OJS) and the generous sponsorship of the University of Pittsburgh's Office of Scholarly Communication and Publishing University Library System.As context, this issue was produced during an historic time. COVID-19, a global pandemic, is still dramatically affecting healthcare worldwide, as well as the global economy. Submissions to IJT have continued to increase, ostensibly to document how telerehabilitation is meeting those challenges. We regret that we are unable to publish the high volume of articles that are being submitted. Instead, we strive to promptly suggest other placements for work that is not central to telerehabilitation or relevant to the larger IJT audience.International Journal of Telerehabilitation (IJT) features impactful research across rehabilitation disciplines, with many more articles about physical therapy  than has been typical. The issue also includes the conference proceedings of an inter-professional educational effort that underscores that telerehabilitation at its best, is enriched by multi-disciplinary collaboration.The current issue of the multi-disciplinary We cordially invite submissions to the June 2022 issue beginning on January 1, 2022. IJT accepts original research, case studies, viewpoints, technology reviews, book reviews, and country reports that detail the status of telerehabilitation.Sincerely,Ellen R. Cohn, PhD, CCC-SLP, ASHA-F, IJT EditorJana Cason, DHSc, OTR/L, FAOTA, Senior Associate Editor


The systems biology markup language (SBML) is an extensible standard format for exchanging biochemical models. One of the extensions for SBML is the SBML Layout and Render package. This allows modelers to describe a biochemical model as a pathway diagram. However, up to now, there has been little support to help users easily add and retrieve such information from SBML. In this application note, we describe a new Python package called SBMLDiagrams. This package allows a user to add a layout and render information or retrieve it using a straightforward Python API. The package uses skia-python to support the rendering of the diagrams, allowing export to commons formats such as PNG or PDF.github.com/sys-bio/SBMLDiagrams). Users can install the package using the standard pip installation mechanism: pip install SBMLDiagrams.SBMLDiagrams is publicly available and licensed under the liberal MIT open-source license. The package is available for all major platforms. The source code has been deposited at GitHub (Bioinformatics online. The systems biological markup language (SBML) . The following is an example that illustrates some simple operations.SBMLDiagrams can be used to read and edit the layout and render of an existing SBML model which can be subsequently exported to an updated SBML model. A variety of color formats (as well as opacity) are supported including decimal RGB, HEX string and all the HTML names (import SBMLDiagrams# load SBML from a file (or string)df = SBMLDiagrams.load(’mymodel.xml’)print(df.getNodeSize (“ATP”))print(df.getReactionFillColor (“ENOLASE”))df.setNodeTextPosition df.setNodeFillColor df.setNodeTextFontColor df.setReactionLineThickness newSbmlStr = df.exportpypi.org/project/skia-python/). Users can export the SBML networks as PNG, JPG or PDF files. The visualization is based on skia-python df = SBMLDiagrams.load(r.getSBML)df.autolayoutdf.drawdf.draw will display the network at the console. Users can also save the figure to a file, for instance, df.draw(output_fileName = ’fileName.pdf’).For most Python IDEs, Autolayout is provided by NetworkX and is useful when an SBML model has no layout information. By use of drawing primitives it is also possible to specify networks that use some aspects from SBGN (pypi.org/project/SBMLDiagrams/) and installed using the standard pip mechanism: pip install SBMLDiagrams. The package is fully documented as https://sys-bio.github.io/SBMLDiagrams/.SBMLDiagrams is available as a pip package (btac730_Supplementary_DataClick here for additional data file.


The saphenous vein is the most used conduit for coronary artery bypass surgery.However, the patency rate of this graft is inferior to the internal thoracicartery patency rate, which is the gold standard. Using the conventionaltechnique, the saphenous vein is harvested via a large open incision and excisedin such a way that causes both vascular damage and wound healing complications.Consequently, vein graft patency and surgical site infection may be compromised.Graft patency is markedly improved when the saphenous vein is harvestedatraumatically with minimal damage and with surrounding cushion of perivascularfat intact. However, despite the improved graft performance, wound healingcomplications and infection remain a problem. Although wound healingcomplication is reduced when using endoscopic vein harvesting, there may be anegative impact on graft performance. This is due to vascular damage associatedwith application of forces to the vein that are usually avoided in open veinharvesting, including traction, adventitial stripping, and venous compression.There is evidence to suggest that improved patency of endoscopically harvestedsaphenous veins is associated with the surgeon’s experience of the technique.Recently, endoscopic methods of harvesting have been described where thesaphenous vein is removed intact and with minimal vascular damage caused. Inaddition, wound healing complications, infection, and scarring are reduced.While the effect of these techniques on vein graft patency have yet to bereported, the ability to obtain a superior graft with reduced woundcomplications will be of great benefit to patients undergoing coronaryrevascularization procedures. While quite dramatic relaxant oranti-contractile effects of PVAT have been demonstrated in SVs harvested by NTvs. OVH SVs28][and Yamada et al.29][. Preserving PVAT waspredominantly involved in the superior nitrogen oxides production in NT whencompared to conventional SVG49][ and fibrin glue53][ to “extents” madeof Dacron54][. The rationale for using externalstents on damaged conventional SVG ranges from providing mechanical support toprotection against the effect of arterial hemodynamics and the stimulation ofangiogenesis51][.The excision of surrounding tissues and the creation of skin flaps by the NTtechnique of SV harvesting are commonly debated to lead to more extensive tissuedamage. Studies have reported a higher rate of SV harvesting site infection inpatients receiving the NT technique59][. A more recent study by this group providesvideo footage demonstrating an endoscopic NT SVG technique 61][.Given the marked improvement in NT SVG patency and the reduced leg woundcomplications when using EVH, these recent studies may pave the way towards agreater use of NT SVG, securing its position as the second conduit of choice forCABGThe SV is the most used conduit for revascularization in patients undergoing CABG.The patency of conventional SVG is affected by vascular damage caused at harvestingbut is improved dramatically when the vein is prepared with minimal trauma using theNT SV harvesting technique. However, in both cases the SV is removed via large openincision, a situation leading to wound infection, wound healing problems, andscarring. These surgical site problems are overcome using EVH, where the SV isharvested through small incisions using specialized instruments under video control.The limited visual field and other conditions, such as traction and handling byinstruments associated with EVH, may cause damage to the SV, a damage that affectsgraft performance. There is an overall shortage of properly designed prospectiverandomized studies comparing long-term graft performance of EVH vein grafts.Recently, a number of modified EVH procedures have been introduced that protect SVstructure and reduce wound healing complications, infection, and scarring. To date,no follow-up patient studies have been reported using these EVH NT SVG techniques.It is important for such trials to be conducted to determine their effectiveness inproducing superior SVG for CABG with minimal surgical site problems.


Human-in-the-loop (HITL) optimization with metabolic cost feedback has been proposed to reduce walking effort with wearable robotics. This study investigates if lower limb surface electromyography (EMG) could be an alternative feedback variable to overcome time-intensive metabolic cost based exploration. For application, it should be possible to distinguish conditions with different walking efforts based on the EMG. To obtain such EMG data, a laboratory experiment was designed to elicit changes in the effort by loading and unloading pairs of weights  in three randomized weight sessions for 13 subjects during treadmill walking. EMG of seven lower limb muscles was recorded for both limbs. Mean absolute values of each stride prior to and following weight loading and unloading were used to determine the detection rate (100% if every loading and unloading is detected accordingly) for changing between loaded and unloaded conditions. We assessed the use of multiple consecutive strides and the combination of muscles to improve the detection rate and estimated the related acquisition times of diminishing returns. To conclude on possible limitations of EMG for HITL optimization, EMG drift was evaluated during the Warmup and the experiment. Detection rates highly increased for the combination of multiple consecutive strides and the combination of multiple muscles. EMG drift was largest during Warmup and at the beginning of each weight session. The results suggest using EMG feedback of multiple involved muscles and from at least 10 consecutive strides (5.5 s) to benefit from the increases in detection rate in HITL optimization. In combination with up to 20 excluded acclimatization strides, after changing the assistance condition, we advise exploring about 16.5 s of walking to obtain reliable EMG-based feedback. To minimize the negative impact of EMG drift on the detection rate, at least 6 min of Warmup should be performed and breaks during the optimization should be avoided. Future studies should investigate additional feedback variables based on EMG, methods to reduce their variability and drift, and should apply the outcomes in HITL optimization with lower limb wearable robots. The human lower limb is required to execute a variety of movement tasks including locomotion as our most essential means of transport. Physical and functional limitations due to age or disease can limit lower limb-related mobility , or biological peak loads . Combinations of multiple and weighted target variables are possible. When the target variable is known, it is incorporated into a method known as human-in-the-loop (HITL) optimization , define the blood flow and, thus, the oxygen and energy supply to the human body  of the involved muscles. EMG has been shown to increase with increased effort in both dynamic conditions, due to walking speed increase, and static conditions, due to muscle force increase against a fixed element  To be able to compare the loaded and unloaded EMG data, we first aimed to exclude the data from the transition phase between steady-state loaded and unloaded walking conditions. (B) To determine if multiple consecutive strides can improve the detection rate in between the conditions of loaded and unloaded walking compared to a single stride. (C) To determine if a combination of muscles can help distinguish the loaded and unloaded walking. (D) To investigate EMG drift over long periods of time for the same weight conditions as this could limit condition comparisons within HITL optimization.(A) When changing the assistance pattern of a lower limb wearable robot, users must first react to the sudden perturbation due to a change in the assistance pattern and then restore a stable and steady gait. We believe that the transition phase should be excluded from the data comparison within HITL optimization, as in most cases, the user's muscle response will differ from a steady gait. This study is not designed to evaluate exactly how many strides are required for the transition. However, we aim to exclude the transition strides from the following analyses. We believe that a couple of strides should be sufficient to return to a steady gait with constant levels of EMG and EMG variability.(B) For HITL optimization, it is of interest to be able to identify differences in the user response between assistance patterns, in our case based on the human effort determined by EMG. A change in human effort during gait is typically determined by the net metabolic cost  When exploring assistance patterns with lower limb wearable robots the resulting effects on the lower limb muscles are unknown. While some muscles might be assisted, others could require increased effort to compensate for overshooting joint biomechanics or the resistance of the wearable device. Thus, it seems prudent to not only look at involved agonists but to also include antagonists for HITL optimization. Furthermore, as the function of the lower limb joints is closely coupled and dependent on each other, we expect a change in the function of one lower limb joint to induce additional changes in other lower limb joints and muscles and both limbs. For example, when assisting the hip with an exoskeleton the EMG of the soleus and gastrocnemius muscles changed and when assisting the ankle the EMG of the vastus and rectus femoris muscles changed  If changes in EMG amplitude due to signal drift are larger than the changes in amplitude due to the change in walking effort, this could limit the use of EMG within HITL optimization. Thus, knowing the drift will help to specify how to possibly use EMG for HITL optimization. Based on reported changes in EMG due to sweat, temperature, adaptations in walking biomechanics, and other reasons  during treadmill walking . Based oseniam.org). In preparation for sensor fixation, hair was removed from the skin and the skin was cleaned with alcohol. To reduce the chance of loosening due to sensor movement and sweating, sensors were additionally affixed with adhesive non-woven fabric tape (Rudavlies). Each EMG sensor also included a 3D gyroscope (148 Hz). Gyroscopes of the TIB, GAS, and SOL were used to identify individual strides for each limb , vastus lateralis (VAS), glutaeus maximus (GLM), biceps femoris (BCF), tibialis anterior (TIB), soleus (SOL), and gastrocnemius lateralis (GAS). The wireless EMG sensors  were placed based on the recommendations of SENIAM  was performed at a constant speed of 1.3 m/s, which is the preferred walking speed for adults  subjects were instructed by an acoustic metronome to either pick up or release one pair of weights from/to a plate in front of the treadmill located at the height of the navel. In total, 21 intervals of 40 s were performed over 14 min, including 10 repetitions for each pick up and release of the weights, in each of the three weight sessions . SubjectThe EMG and gyroscope data were exported to Matlab  for further processing . GyroscoA method was required to detect the timing of the weight transition, as trial-to-trial variation was expected during transitions after hearing the metronome. A gyroscope was therefore affixed to each weight to record the angular velocity of the weights in three axes. The sum of the absolute value from all three axes was determined. In addition, this sum was filtered with a moving average having a sliding window of half of the EMG frequency. Following this, the sum of the left and right angular velocities was totaled. If the weights are not moving, the combined signal is nearly zero. When walking, the summed gyroscope signal is above 150°/s with larger peaks when picking up or releasing the weight. If a threshold of 40°/s is passed (in either direction), the corresponding left and right strides are considered to be transition strides.The stride identification (heel strike to heel strike of the same limb) is required to separate the EMG data of individual strides. This was accomplished based on the zero crossings of the lower limb segment angular velocities  and rectified. Only for the time-normalized EMG over one stride and its differences between the loaded and unloaded conditions  were EMGAs we realized that several EMG signals showed clear measurement artifacts, four strategies were applied to remove them. It should be noted that all strides that partially contained artifacts remained within the dataset to avoid temporal displacements but were excluded (replaced by NaN in Matlab) from each of the analyses.First, phases with distinct changes in the EMG signal  that happened within the 14 min sessions and that lasted for longer periods  were completely excluded. For each subject, on average 5 of 14 muscles showed at least at one point during the four sessions a phase with a distinct change. With this method, about 6.5% of the data were excluded in total.Second, distinct EMG peaks including 1 s prior to and following the peaks were excluded. Distinct peaks had more than three times the signal amplitude compared to the regular EMG peaks (mean peak height over the session) during walking. On average, about one error peak occurred per muscle within each 14 min session.Third, next to distinct long-term and short-term changes in amplitudes, artifacts with similar amplitudes as the expected EMG signals, but with changes in duration or frequency of occurrence, were identified. To reduce the number of such artifacts, we explored different low cutoff frequencies for the bandpass filter. Typically the use of 10–20 Hz is reported  of the EMG for each stride was determined, as this is our main variable for the EMG analyses.5, or approximately 0.1%).The MAV was also used to exclude artifacts with similar amplitudes but prolonged time durations. Strides with MAVs that were five times above the SD of the mean MAV for each individual muscle, subject, and session were excluded  and the grand mean of the intra-subject SD of the MAVs (MAVstridestd) were used. After normalization of the MAVs with a reference  that should not be considered for the loaded and unloaded conditions during the EMG data comparison. For this analysis, the grand mean of the MAVs . Due to the normalization to the reference of 100%, the post-transition value of MAVstride shows the relative change in EMG amplitude compared to the previous weight condition . The individual intra-subject SD was determined for the same 110 strides of each subject based on the 10 transitions to each weight condition for each of the three weights. The mean of this individual intra-subject SD was then determined for all muscles, and the grand mean MAVstridestd was then determined by taking the mean of all subjects.Following this, the mean of the MAVs (over the 110 strides) of both the 10 pick up and the 10 release transitions were determined . These means were used to determine the mean of all muscles (for each weight and subject). As a final step, these means were used to determine the MAVn, where n ∈  corresponds to the prior transition strides, and n ∈  corresponds to the post transition strides.After excluding the positive and negative offset and transition strides (transition process), the condition analysis was performed. The condition analysis includes up to 40 strides prior to and up to 40 strides post the transition process. The strides are indicated with n of i consecutive strides (left and right combined), where i ∈  is investigated for both the reference prior and the comparison condition post the transition. MAVn denotes the muscle MAV of the nth stride. Then the mean of the i strides prior to the transition MAVi, prio is defined asIn the condition analysis, the MAVs were used to analyze whether it is possible to distinguish an increase or decrease in EMG after reaching steady walking following transitions between loaded and unloaded conditions. In contrast to the transition analysis, where each stride following the transition was compared separately to the whole reference condition prior to the transition, here the mean of the MAVi strides post to the transition MAVi, post is defined asThe mean of the i = 10, five left and five right consecutive strides) the mean of the last 10 strides before the transition of interest . In the case of picking up the weight, an increase in muscle activity would be expected, which would result in a normalized MAVi, post of larger than 100%. In the case of releasing the weight, the opposite would be expected to occur.The consecutive prior (reference) and post (comparison) transition strides always start close to the transition of interest. For example, for the case of the 10 stride combination  and the stride combinations for one to 40 strides.At this stage, a data structure exists, which contains 13 subjects, each with three different weights, and each containing seven muscles (left and right combined). Each muscle contains a matrix with 20 x 40 values that includes the MAVi, post from the included muscles were determined. For example, for a combination of two muscles where one had a MAVi, post of 103% and the other of 107%, the combined mean MAVi, post would be 105%.A decision must be made regarding which of the seven muscles or which combination of muscles should be analyzed. We decided to analyze all possible 127 muscle combinations including either one (7 possible combinations), two (21), three (35), four (35), five (21), six (7), or seven (1) muscles. For combinations of muscles, the means of all values of MAVK equals 130. Let k ∈  indicate the kth measurements. Following this, from all subjects and transitions, we counted the number of changes where the change of muscle activity occurred in the expected direction (Ek).Based on 10 transitions and 13 subjects for each the pick up and the release of weight, in the best case without any exclusions due to the artifact removal, the total number of evaluated transitions i, prio, k and MAVi, post, k denote the prior and post transition MAVs of the kth measurement.Then MAVFor a pick up of weighti, post of the kth transition increases as expected, and 0 if it unexpectedly decreases also while picking up a load. In case of releasing of weightis 1 if the MAVi, post of the kth transition decreases as expected, and 0 if it unexpectedly increases also while releasing a load. Thenis 1 if the MAVis the number of transitions that behave as expected for each pick up and release. The detection rate is defined asand is calculated for all 127 muscle combinations and the three weights.i, post we focused our detailed analysis on specific questions.As we can not present the results for all 127 muscle combinations for both transitions and for each MAVTo identify differences in the pick up and the release behavior for DR, the grand mean  of all 127 muscle combinations was determined for each transition case (pick up and release) separately . Additioi involved strides after the transition) based on the number of involved muscles. For example, in the case of two-muscle combinations, the mean of 21 combinations was determined. For this analysis, the values for the pick up and release were combined (mean).To investigate whether the identification of the weight change can be improved by increasing the number of involved muscles , we calci involved strides were determined  and lowest (Worst) grand mean  of all DR for termined . To showi, std of the MAVi, post was determined. To obtain the MAVi, std, for each subject and each muscle the STD of the MAVi, post of both the 10 pick up and 10 release transitions were determined. Following this, the STD was averaged over all muscles and then over all subjects. For the results presented in i, std was determined.To better understand the reason behind the changes in the detection rate with an increased number of muscles and strides, the grand mean of the intra-subject STD MAVint) was separately determined from the loaded and unloaded conditions. To compute MAVint, all but the positive and negative offset MAVs and the two transition MAVs were averaged for each interval and all subjects. Similar to the normalization approach explained previously, these values were normalized to be 100% for the first interval (unloaded) of the first session after Warmup. These values were then used and averaged over all 14 muscles to determine MAVint and the related SD between the muscles MAVintstd.To identify how the MAV drifts over time during walking , insteadWhen walking for approximately 40 s at 1.3 m/s for each interval, subjects took an average of 65 strides for the left and right limbs combined. Stride time did not change considerably for the different weights and conditions .stride) of 2.1, 4.4, and 9.5% were found when picking up the weight, and –2.4, –4.3, and –8.4% were found when releasing the weight for 2, 4, and 8 kg, respectively  12.1, 12.3, and 13.5% for picking up, and 11.3, 11.1, and 11.1% when releasing the weight of 2, 4, and 8 kg, respectively  reveals a minimum DR of 50% for a single subject after 10 strides, 65% for two subjects after 20 strides, and 70% for two subjects after 40 strides .i, std) was found to decrease greatly with an increased number of combined strides and increased number of muscles for all weights (The grand mean of the intra-subject SD (MAV weights .int) during the course of the whole experiment for the loaded and unloaded conditions, we found a clear negative drift (int changed from 116% at the beginning of session 1 (Warmup), to 100% at the beginning of session 2, and to 88% at the end of session 4. Similar drift was found for the loaded condition where MAVint dropped with respect to the unloaded condition from 106% at the beginning of session 2 to 91% at the end of session 4.When analyzing the grand mean interval MAV  was within the process. As the acoustic metronome was not perfectly synchronized with the EMG and subjects reacted at different times after hearing the metronome, we did not use the metronome as the event to evaluate the duration of the transition. Additionally, as it was not the main focus of our study, we decided to use one duration for all conditions even though the negative or positive offset could be reduced for individual subjects, amount of weight, the pick up condition, or the release conditions.Literature shows that transitions where the environment forces a transition, such as a transfer from level walking to stair ambulation, are realized within three strides  was, as expected, highly beneficial for DR, where the largest increases were found for the first few added strides. For the best muscle combination, increases of 15 and 20% were found when averaging over 10 strides while 30 strides simply improved DR by another 9 and 5% for the 2 kg and 4 kg conditions, respectively. The DR with 8 kg weight settled to nearly 100% after 10 strides. Thus, based on our study, we would advise using at least 10 strides (about 5.5 s) for HITL optimization. Similar values were identified in Shiavi et al. . HoweverAs expected, with an increased number of included muscles DR increased. For all three weights, the seven-muscle combination was close to the best achieved performance . Our datHowever, as there is a variety of possible manipulation scenarios for lower limb robotics including the hip, knee, and ankle, or combinations of these joints, it will be a challenge to select those muscles that are primarily affected. For example, when assisting the hip also the EMG of the SOL and GAS changed  the distribution of the estimator will be more narrow and the distinction between loaded and unloaded conditions will improve. However, with every increase of n, for either strides or muscles, the level of DR improvement decreases , the sample mean will also be normally distributed with the SD. The sample SD ecreases . For musThese findings suggest that the reduction in EMG variability due to biological and non-biological sources is key to improving the usability of HITL optimization. Thus, future studies should explore methods to reduce EMG variability. In addition, other time and frequency domain EMG features . The detection rate  and its int over the whole experiment increased and covered a range from 134% at the beginning of the Warmup to 82% within session 4, a range of 52%, compared to 28% when using the artifact removal. Without artifact removal, the STD of MAVint doubled.In contrast, without the artifact removal, the drift of MAVOne possible source of the artifacts could be the weight (14 g) of the new generation of mobile EMG sensors, which include additional electronics . Human wobbling masses of the thigh and shank were found to move within 3–55 Hz following the impact during heel-toe running . As drift occurs at low frequencies, this can be minimized using such a filtering approach. While the drift reduction did not further improve the detection rates, it would improve the ability for HITL comparisons of early and late assistance patterns over 1 h of optimization. As we found no other reference for the explored behavior, we would recommend assessing whether a similar EMG behavior exists for other data sets as well.One curiosity was explored within our evaluation. We suspected that lower cutoff frequencies of the bandpass filter above 10–20 Hz would considerably change the means of the EMG data . HoweverWe decided to select and mainly publish results with the 40 Hz lower cutoff frequency for the bandpass filter, as this covers most of the identified improvements due to the artifact and drift removal.This study explored the mean absolute values (MAV) of lower limb EMG during walking during loaded and unloaded conditions, with the aim of using the MAVs for HITL optimization. We found that transition strides between the loaded and unloaded conditions have increased MAV amplitudes compared to the previous and following steady-state conditions, which could cause a misinterpretation of the condition comparison in HITL optimization. As we aimed to compare steady gait conditions, we excluded 30 transition strides from each analyzed transition. However, based on literature and visual observation of the individual conditions, the exclusion of 3–20 strides seems sufficient for transition scenarios when changing assistance patterns in lower limb wearable robots. Further, we found it is worthwhile to combine the MAVs of multiple strides for both the reference condition and the comparison to improve the detection rates for changes in EMG. Based on our findings we recommend using the mean MAV of at least 10 strides. To increase sensitivity, 40 strides or more can be beneficial. Thus, based on the 20 strides for the transition and the 10 strides for the observation, we recommend approximately 16.5 s in total as the time window per observation for HITL optimization. This is less than half of that mentioned by Han et al.  and woulThis study also explored the drift of the MAVs over the course of the whole experiment. We found that a large drift exists within the Warmup and after the breaks. We would recommend performing at least 6 min of Warmup to reduce the effect of drift and avoid breaks within the HITL optimization. The lower cutoff frequency of the bandpass filter turned out to be a great modulator to eliminate artifacts as well as the MAV long-term drift. Without eliminating the drift, we would not recommend comparing the absolute values of the early MAVs to MAVs in later stages of a HITL experiment as the change in the MAV due to drift is larger than the change in the MAV when transitioning from unloaded walking to loaded walking with our largest load evaluated of 8 kg.All the data relevant to this study are presented within the manuscript. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.The studies involving human participants were reviewed and approved by the Institutional Review Board, Technical University of Darmstadt. The patients/participants provided their written informed consent to participate in this study.MG was responsible for funding acquisition, analyzed the data and prepared the related figures, and wrote the original draft. MG, JZ, FW, and GZ were responsible for the experimental design. MG, JZ, and FW performed the experiments. All the authors interpreted the data. and provided critical feedback on the manuscript.www.dfg.de) under Grant No. KO 1876/15-1. We acknowledge support from the German Research Foundation and the Open Access Publishing Fund of the Technical University of Darmstadt for covering publication costs. None of the funding sources had any influence on the design of the study and collection, analysis, and interpretation of data.MG was funded by the German Science Foundation (DFG) under the Grant No. GR 4689/3-1 and the Technische Universität Darmstadt by the Athene Young Investigator Funding (No. 52700967). The funding for JZ was provided by the German Science Foundation (DFG, The 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.


To compare the histological properties and stretch of colorectal mucosal grafts (CMG) and buccal mucosal grafts (BMG) and to evaluate the impact of age, medical comorbidity and tobacco use on these metrics.Samples of BMGs from patients undergoing augmentation urethroplasty were sent for pathologic review. CMGs were collected from patients undergoing elective colectomy. CMGs were harvested fresh, at full thickness from normal rectum/sigmoid. Patients with inflammatory bowel disease, prior radiation, or chemotherapy were excluded.Seventy two BMGs and 53 CMGs were reviewed. While BMGs and CMGs were both histologically composed of mucosal (epithelium + lamina propria) and submucosal layers, the mucosal layer in CMG had crypts. The outer epithelial layers differed significantly in mean thickness . Mean lamina propria thickness and submucosal layer thickness also differed significantly . Mean delta stretch, as to length and width, was greater for CMG (118% x 72%) compared to BMGs (22% x 8%), both p<0.001.CMGs and BMGs significantly differ histologically in layer composition, width and architecture, as well as graft stretch. Given its elastic properties, CMG may be useful in covering large surface areas, but its thin epithelium, thick lamina propria and additional muscularis mucosal layer could impact graft take and contracture. The buccal mucosal graft (BMG) is the most widely used graft for urethral reconstruction . Unique Certain patients may have specific relative or absolute contraindications to BMG use, such as: prior BMG harvest, surgery or radiotherapy for oral cancer treatment, active tobacco use or oral mucosal diseases. Poor oral health has also been shown to impact BMG histologic characteristics . MoreoveAs an alternative to buccal grafts, colorectal mucosal grafts (CMGs) can be utilized and have recently been shown, in several small series, to successfully treat complex long urethral strictures –15. AlthWhile both grafts have demonstrated clinical applicability, it is unknown how their physical and histologic properties compare. These characteristics are important to analyze as they may favor the ‘take’ of one graft over the other in urethral reconstruction. Therefore, the purpose of this study was to compare the histological properties and stretch characteristics of CMGs and BMGs. We hypothesized that CMG and BMGs would differ in cell layer thicknesses and in graft stretch.We conducted a prospective analysis of all patients who underwent BMG urethroplasty at our institution and consented to participate. CMGs were collected from all consenting patients who underwent elective colectomy or proctectomy. Colorectal patients with inflammatory bowel disease, prior radiation, or chemotherapy were excluded. All surgeries were performed between 2018 and October 2021. This study was approved by the institutional review board (AAAS3576).The protocol and technique for BMG harvest has been previously described and was standardized across all patients . An ovoiGraft measurements were taken with the graft on a silicone block, both on and off stretch. Excess BMG not needed for urethral reconstruction was sent to pathology for analysis. The defect in the mouth after graft harvest was measured and recorded.Colectomy/proctectomy was performed by a board-certified colorectal surgeon and immediately sent to pathology. All CMG specimens were obtained within six hours from resection and not contaminated by formalin. A full-thickness 5 × 2 cm was measured and marked by a member of the research team, along a segment of palpably and visibly normal colon or rectum. The graft was excised, and the mucosa was dissected off the underlying muscularis propria layer. Unlike BMGs, there was no grossly visible layer that needed to be defatted. CMG dimensions were obtained in a similar fashion to BMGs, with the graft placed on a silicone block, on and off stretch.Histological review of all grafts was performed by a single staff pathologist. Tissue was sent in 10% buffered formalin, grossed, and embedded in paraffin block. Hematoxylin and eosin (H&E) staining was performed on 5-μm tissue sections on glass slides. A minimum of 10 high power fields were examined for each prepared slide. Measurements were taken from three 100x fields using an Olympus (Japan) BX41 microscope using a U-OCM10/100 eyepiece reticle 1 mm micrometer. Digital images were taken with an Olympus QColor3 camera using QCapture software .Average epithelial, lamina propria, and submucosal thickness were measured and recorded. A modified version of the previously established Oral Mucosa Rating Scale was used to quantify the type and severity of pathological mucositis for all grafts. This scale was originally developed to assess for the severity, on a scale of 0 to 3, of seven types of clinical mucosal changes considered to be manifestations of clinical oral mucositis .Graft stretch was assessed using the following formula: (Ds-Dd)/(Dd)*100%. Where Ds is equal to the dimension (length or width) of the graft stretched on the silicone block after macroscopic defatting (for BMGs) or muscularis propria removal (for CMGs) and Dd is equal to the corresponding dimension (length or width) of the graft defect. Graft stretching was performed manually by using pins to secure the grafts on a block. Force required to stretch the graft over a unit of length was not measured or calculated.Chi-squared and Fisher's exact tests were used to assess for differences in the clinical characteristics between BMG and CMG patients. Two-tailed t-tests were used to compare means and differences in graft characteristics, including stretch and histologic metrics. Individual multivariable linear regression models were used to evaluate the association between three hypothesis-driven patient-level covariates ), and graft characteristics for each graft type (BMG versus CMG). Statistics were performed using Stata/IC v16.1 .Seventy-two BMGs and 53 CMGs were harvested. To our knowledge, this is the first report in the literature to investigate and compare the histological and stretch characteristics of buccal and colorectal grafts. We found that each graft type had differing characteristics that could either be potentially beneficial or detrimental to graft success. We believe that our findings are important for clinical practice as they demonstrate that colorectal mucosa may not be a perfect substitute for buccal mucosa, and that this may require consideration during surgical decision making and planning.We found that BMGs and CMGs had similar overall thicknesses but differed significantly in the dimensions of their individual cell layers. BMGs had a significantly thicker epithelium than CMGs but a significantly thinner LP. This is similar to what has been previously reported in comparisons of oral mucosa to bladder mucosa and penile skin . It is aBuccal mucosa is a successful substitution tissue in urethral surgery because of its inherently thick elastin-rich epithelium, which makes it tough yet easy to handle, and its thin, highly vascularized LP, or subepithelial connective tissue layer, which is believed to facilitate early inosculation and imbibition , 21. ItsPrior literature has suggested that LP width is particularly important for graft take, as it enhances basal epithelial cell viability and facilitates neovascularization of the graft . The LP Extrapolating from studies in skin grafting, we suspect that the thickness of the elastin-rich epithelial layer in mucosal grafts could impact graft contracture. Graft contracture occurs in two stages: primary and secondary contracture. Primary contracture, which refers to the immediate contraction that occurs directly after graft harvest, is due to passive recoil of elastin fibers and is directly dependent on the thickness of the elastin-rich dermis. Whereas secondary contracture, which refers to graft contraction on the wound bed, is caused by myofibroblasts deposition and is inversely related to dermal thickness . While aOur finding that BMGs were significantly less elastic than CMGs on the back-table silicon block seems to support our hypothesis about primary graft contracture. We found that, on average, CMGs could be stretched to more than double their initial excision size on the back-table. On average a 5×2cm CMG graft, could be stretched to cover a 10.9×3.4cm defect, while a BMG could only cover a 6.1×2.2cm defect. Though little is known about the clinical importance of ex-vivo graft stretch, the significant gains in length and width in CMGs, could mean that a relatively smaller CMG could be used to cover a much larger defect than a BMG. While this characteristic would be particularly important in patients with long urethral strictures or limited oral mucosal availability, it remains unclear if CMG elasticity is durable in-vivo or if it becomes compromised by secondary graft contracture.We also demonstrated that CMGs have an entirely extra cell layer, the muscularis mucosa (MM), compared to BMGs. This layer is relatively thin, approximating one-tenth the thickness of the epithelial and LP layers and is located deep to the LP but above the submucosa. The inner MM layer is made of a thin layer of smooth muscle. It supports and enables the mucosa to move and fold. Below it, is the submucosa – which is a thick connective tissue layer containing vasculature, lymphatics, and nerves . The cliWhile age, tobacco use, and CCI did not seem to have a correlation with graft stretch for each graft type, these covariates did appear to affect cell layer thicknesses. Age was inversely related to the epithelial thickness of buccal grafts. This was consistent with findings that we previously published in a smaller cohort . IncreasThis study has several limitations. First, it is a single-center, single-surgeon, single-pathologist study. Second, not all BMGs resulted in pathology review. Third, our buccal patients tended to be younger and healthier, and our colorectal patients tended to be smokers, which could have impacted the qualities of our grafts, however we did control for these factors in our models to mitigate this risk. In addition, our cohorts were small, and the CMGs were collected from several different anatomic locations along the gastrointestinal tract. And last, graft stretch was assessed manually without accounting for applied force. In addition, this was not an outcomes study – therefore we do not have clinical outcomes data to correlate with our histologic findings.Our study is the first to compare the histologic properties and stretch characteristics of buccal and colorectal mucosal grafts. It also raises the question of whether certain demographic and clinical factors should influence surgeon-decision making in selecting graft type. Though more work is needed, our findings suggest that buccal grafts may continue to be a more suitable graft for urethroplasty due to their relatively thicker epithelium and thinner LP. That said, the significant elasticity of colorectal grafts may make colorectal grafts a more suitable options in patients with longer, more complex urethral strictures, or in patients who have limited oral graft availability or oral pathology. However, the durability of this elasticity during healing remains unknown. In-vivo studies, either in animal models or humans, are needed to determine if graft selection and histologic properties affect graft take, urethroplasty outcomes and the risk of stricture recurrence.


It is well known that arterial stiffening is one of the earliest detectable signs of structural and functional alterations of the arterial wall. It occurs as a result of aging but also occurs prematurely, caused by atherosclerosis as a result of different cardiovascular risk factors, e.g., hypertension, diabetes, smoking, obesity or chronic kidney disease, because of which media of the arterial wall undergoes structural and functional changes, resulting in reduced distensibility. The loss of elasticity and increased rigidity results in increased velocity of pulse waves since they travel faster in stiff arteries. Many studies have reported different physiological and pathophysiological conditions associated with increased arterial stiffness . For insSome of the studies on arterial stiffness have been published most recently shedding a new light on this topic. Literature data suggested a correlation between serum magnesium levels in the upper part of the distribution and lower arterial stiffness parameters . HoweverA very interesting recently published systematic review suggested an association between gut microbiota composition and arterial stiffness, with two patterns in most animal and human studies—a direct correlation between arterial stiffness and abundances of bacteria associated with altered gut permeability and inflammation; an inverse relationship between arterial stiffness, microbiota diversity, and abundances of bacteria associated with most fit microbiota composition. However, interventional studies showed a stable association between microbiota modification and arterial stiffness only in animals but no human interventional trial was able to demonstrate this relationship .It has been mentioned already that obesity is also associated with an increased arterial stiffening. Therefore, it is not a surprise that a recent meta-analysis has shown that the arterial stiffness is improved after bariatric surgery in extremely obese subjects . A recenParticularly interesting question is whether arterial stiffness, as an established independent predictor of cardiovascular risk, is increased in patients with familial hypercholesterolemia (FH). FH is, because of life-long exposure to elevated serum levels of LDL-cholesterol, the most important risk factor for accelerated and premature atherosclerotic cardiovascular disease. A number of studies demonstrated a significant positive relationship between artery stiffness and total cholesterol and/or LDL-cholesterol and they particularly showed an increased arterial stiffness in patients with FH . A meta-Nevertheless, increased arterial stiffness is associated not only with risk factors for atherosclerosis. It has been shown recently that arterial stiffness might be a strong prognostic parameter in heart failure patients discharged after an acute heart failure decompensation .As a conclusion, it could be stated that arterial stiffness is more and more in the focus of interest of different studies trying to find whether this might be another reliable biomarker for early detection of increased cardiovascular risk and the accumulated data seem to be very much in favor of a positive answer.


Pan American Journal of Public Health draws readers’ attention to an error in the following article, pointed out by the authors.The In page 3, table 1, HC.3.4 Outpatient long-term care , should read HC.3.4 Home-based long-term care .


For accurate and sensitive chimerism analysis, a set of KMR kits , based on detection of insertions/deletions (indels) by qPCR, have been developed. Here, we investigated informativity and validated the accuracy of KMR kits in Japanese donor/recipient pairs and virtual samples of DNA mixtures representative of Japanese genetic diversity. We found that at least one recipient-specific marker among 39 KMR-kit markers was informative in all of 65 Japanese donor/recipient pairs. Moreover, the percentage of recipient chimerism estimated by KMRtrack correlated well with ratios of mixed DNA in virtual samples and with the percentage of chimerism in HSCT recipients estimated by STR-PCR/in-house SNP-qPCR. Moreover, KMRtrack showed better sensitivity with high specificity when compared to STR-PCR to detect recipient chimerism. Chimerism analysis with KMR kits can be a standardized, sensitive, and highly informative method to evaluate the graft status of HSCT recipients.Chimerism analysis is a surrogate indicator of graft rejection or relapse after allogeneic hematopoietic stem cell transplantation (HSCT). Although short tandem repeat PCR (STR-PCR) is the usual method, limited sensitivity and technical variability are matters of concern. Quantitative PCR-based methods to detect single nucleotide polymorphisms (SNP-qPCR) are more sensitive, but their informativity and quantitative accuracy are highly variable Sufficient hematopoietic and immune reconstitution by replacement of recipient-derived cells with donor cells is critical for successful allo-HSCT3.Allogeneic hematopoietic stem cell transplantation , including peripheral blood (PB) stem cell transplantation (PBSCT), bone marrow (BM) transplantation (BMT), and cord blood (CB) transplantation (CBT), can be a curative intervention for various hematologic diseases. However, allo-HSCTs often show comorbidity or mortality due to relapse of the hematologic disease, infections, graft-versus-host disease (GVHD), and graft failure associated with graft rejection or poor graft function5. The major techniques of chimerism analysis are PCR for short tandem repeat (STR) profiles of DNA (STR-PCR), and detection of single nucleotide polymorphisms (SNPs) with real-time quantitative PCR (qPCR)-based methods (SNP-qPCR)7. Although STR-PCR is the predominant method, technical variability among laboratories is pronounced, and the detection limit for recipient chimerism is not very low, ranging from 1 to 10% among studies13. SNP-qPCR is a fast and sensitive method to detect recipient chimerism below 1%, but there are issues such as limited informativity, inconsistent quantitative accuracy, false positive results, and technical variations12. Thus, chimerism analysis lacks methodological standardization and might not discriminate between donor and recipient cells with sufficient reliability13.Chimerism analysis assesses proportions of hematopoietic cells from the donor (donor chimerism) and recipient (recipient chimerism), and it is used as a confirmation of engraftment and as a surrogate indicator for graft rejection or relapseRecently, KMR kits  have been developed as a set of standardized products prepared for chimerism analysis using a real-time qPCR-based assay. Appropriate markers can be screened from among ready-to-use primers for 39 different chromosomal locations in the KMRtype Core and Extended kits, followed by post-allo-HSCT chimerism monitoring with KMRtrack using the primer(s) selected by the KMRtype kits. The 39 KMR markers, which are commercially available as CE-IVD markers, detect specific insertions/deletions (indels) that consist of multiple nucleotides instead of single nucleotides as in SNP-qPCR. As for methodologies and standardization in chimerism analysis, genetic diversity and distribution of indels may differ among ethnic groups of donors and recipients, for which reason KMR kits should be validated in specific contexts. Here, we assessed the informativity and accuracy of chimerism monitoring using KMR kits on samples drawn from an ethnic Japanese cohort.15.Genomic DNA was extracted using the QuickGene DNA whole blood kit S  or the SMITEST EX-R&D  from 130 individuals comprising 65 Japanese donor/recipient pairs who underwent allo-HSCT at Fukushima Medical University Hospital between January 2009 and March 2021 . DNA samples with > 1.8 260/280 nm ratio were mixed carefully for generation of virtual samples. We also tested post-allo-HSCT DNA samples from recipient PB or BM cells. In these samples, values of recipient chimerism obtained by KMRtrack (KMR recipient chimerism) were compared with those of STR-PCR or in-house SNP-qPCR, which had been performed as routine examinations for clinical practice.To screen for informative markers that can distinguish donor and recipient cells, pre-allo-HSCT DNA samples purified from pairs of donors  and recipients  were used in KMRtype Core and, as necessary, KMRtype Extended kits (GenDx). Virtual samples of DNA mixtures with known concentrations obtained from healthy Japanese volunteers were used to validate KMRtrack (GenDx), a tool intended for chimerism monitoring. Concentration of DNA was measured by the absorbance at 260 nm in a spectrophotometer , which is guided by local policy, national law, and the Declaration of Helsinki.17. In-house SNP-qPCR was performed with the sets of primers and probes specific for 5 SNPs 18, using a QuantStudio 3, followed by analysis with QuantStudio Design & Analysis Software v1.4.3 (Thermo Fisher Scientific).For STR-PCR, 20 STR markers  were amplified using a GeneAmp PCR System 9700  as described previouslyAnalysis with KMR kits, which are ready-to-use products prepared for real-time qPCR-based assay, was performed using 10 ng aliquots of DNA from each sample according to manufacturer’s instructions. These kits consist of KMRtype and KMRtrack for pre-allo-HSCT screening and chimerism monitoring after allo-HSCT, respectively. KMRtype Core contains 10 multiplexed primer mixes for 30 markers to distinguish donor-derived and recipient-derived cells for pre-allo-HSCT screening; KMRtype Extended contains 9 additional markers for cases without an appropriate marker in the KMRtype Core set  without any recipient-specific marker in the KMRtype Core kit, resulting in 100% informativity of the KMR kits with recipient-specific markers for the 65 Japanese donor/recipient pairs. However, even with both KMRtype Core and Extend kits, 6 pairs had only one recipient-specific marker  could distinguish 62 of 65 pairs (95.4%). With these 7, we tested the accuracy and reproducibility of KMR markers for estimating ratios of recipient cells with the KMRtrack kit, using virtual samples with known concentrations of mixed DNA from 2 individuals. For samples with ≥ 1% of virtual recipient DNA, values of KMR chimerism determined by these markers correlated highly with ratios of DNA concentrations from 2 individuals, mixed to simulate recipient chimerism  and 21 with mixed chimerism according to STR-PCR or in-house SNP-qPCR with recipient-specific markers previously tested in our laboratory. The values of KMR recipient chimerism correlated well with those of STR-PCR/in-house SNP-qPCR recipient chimerism  had ≤ 2 recipient-specific markers, whereas in our cohort, 6 of 65 donor/recipient pairs (9.2%) had ≤ 2 recipient-specific markers from the KMRtype Core kit. Our results suggest that KMR kit markers enable us to perform appropriate chimerism analysis in a wide variety of donor/recipient pairs. A limitation is that although use of multiple recipient-specific markers is recommended for chimerism monitoring, one unrelated and 5 related pairs had only one recipient-specific marker by using both KMRtype Core and Extended kits. This may be consistent with a recent study that showed at least 40 markers are required to distinguish a large number of the pairs26. There is another issue that some markers frequently showed atypical results which could not determine chimerism.The numbers of recipient-specific, donor-specific, and overall total of informative markers in the KMRtype Core kit were significantly greater for unrelated pairs than for related pairs, probably reflecting smaller disparities within families than among unrelated members of a general population. This was even the case for unrelated pairs with matched HLA compared to related HLA-haploidentical pairs with greater disparities in their HLA alleles. High genetic similarity outside the HLA region in related HLA-haploidentical pairs might contribute to successful HLA-haploidentical allo-HSCT7. For donor/recipient pairs with only one marker, we should be aware that accuracy is an important but challenging characteristic.Next, assessment of the KMRtrack kit using virtual pairs consisting of DNA from 2 different individuals showed good correlation between measured and simulated degrees of chimerism, with sensitivity high enough to detect thresholds of 0.1%-0.3% of an amount as small as 10 ng of DNA. Likewise, values of KMR recipient chimerism correlated well with values from previous chimerism analyses performed with STR-PCR or in-house SNP-qPCR. Although KMR recipient chimerism values tended to be lower than the simulated recipient chimerism values of virtual samples or STR-PCR/in-house SNP-qPCR chimerism in post-allo-HSCT samples, KMRtrack detected minor recipient chimerism even in post-allo-HSCT samples for which STR-PCR did not detect recipient chimerism. This indicates better sensitivity of KMRtrack versus STR-PCR, together with the assessment of virtual samples, described above. In contrast, STR-PCR did not detect recipient chimerism in the post-allo-HSCT samples that were negative for KMR recipient chimerism. These findings suggest sufficient quality, sensitivity, and specificity of the KMRtrack kit for chimerism monitoring. However, a limitation is that positivity of the KMRtrack kit does not distinguish between homozygous and heterozygous state of the marker. In addition, there was a certain variability among KMR markers in chimerism monitoring  using KMRtrack. The results of chimerism by qPCR and cdPCR highly correlated with each other. They also found that chimerism results of a next generation sequencing method highly correlated with those of qPCR with KMRtrack10. Our data and these findings together indicate the excellent utility of KMR kits for chimerism analysis with various qPCR and digital PCR technologies. For indel based chimerism analysis, including qPCR and digital PCR with KMR markers, as well as next-generation sequencing, use of multiple markers is recommended to increase accuracy of the tests, regarding the examples like chromosomal abnormalities coinciding with the markers’ position in relapses.The requirement of only 10 ng DNA for sensitive chimerism analysis may be an advantage of the KMRtrack kit, as demonstrated herein. It is possible that higher doses of DNA would further increase sensitivity of the kit’s qPCR reaction, since various other qPCR-based methods usually need volumes of DNA over 100 ng to obtain higher sensitivity than STR-PCRIn conclusion, chimerism analysis with KMR kits is standardized, sensitive, and highly informative to detect recipient chimerism in allo-HSCT recipients. Therefore, this method could harmonize chimerism analysis for detection of recipient cells and serve as a surrogate marker for graft rejection relapse prediction in hematologic malignancies.Supplementary Information 1.Supplementary Information 2.Supplementary Information 3.Supplementary Information 4.Supplementary Information 5.Supplementary Information 6.