Considering a 5-year period, the SROI for a single exoskeleton was 3.75:1, and the SROI for the number of exoskeletons projected to be sold was 2.868:1, thus resulting largely in value for money. This study provides a model for combining economic, social and environmental outcomes that, besides contributing to theory, could be useful for decision-making. Stroke is the third leading cause of death and disability overall worldwide. Upper limb impairment is a common consequence for stroke survivors, having negative impact on their quality of life. Robotic rehabilitation, through repetitive and monitored movements, can improve their status. Developed by a team of researchers at Politecnico di Milano, AGREE is an exoskeleton for upper limb rehabilitation at the stage gate between translational research and clinical validation. Since the cost of this device is particularly high, the present study aimed to provide a framework for assessing its value. The Social Return on Investment (SROI) method, able to grasp the economic, social and environmental impact of an activity, was applied, using expert opinions of a pool of clinical engineers and healthcare professionals from different Italian hospitals to obtain information. Environmental impacts were estimated through Life Cycle Assessment in terms of CO As defined by the World Health Organization (WHO) in 1970, “stroke is rapidly developing clinical signs of focal  disturbance of cerebral function, with symptoms lasting 24 h or longer, or leading to death, with no apparent cause other than of vascular origin” [The latest Global Burden of Disease (GBD) 2019 identified stroke as the second leading global source of death, and the third leading global source of death and disability together, intended as disability-adjusted life years (DALYs) lost [People who survive a stroke often incur disabilities , which cUsually, people who experience a moderate to severe stroke are first hospitalised and then discharged home or to a rehabilitation centre to continue their rehabilitation. In particular, it has been found that continuing rehabilitation even afterwards is beneficial to maintain functional gains and facilitate adjustment . The presence of community services, family and friends , alongsiCommon problems of stroke patients are an impaired capacity of walking and lower confidence in usual activities, such as using public transportation and driving . Moreover, upper limb impairment is one of the most recurring outcomes in patients soon after a stroke, prevalent in 70–80% of patients [Since upper limb impairment after stroke has a significant impact on the ability of the affected person to perform an activity, it negatively affects their quality of life . For thiNevertheless, not all paresis are equally severe, and depending on the severity, the upper limb functionality varies greatly. Hemiparesis is the most important impairment leading to loss of upper limb function, and the severity of hemiparesis correlates with the ability to perform a movement or an action . HoweverIn recent years, the scientific community has shown great interest in the research and development of technologies for upper limb rehabilitation and assistance in performing activities of daily living in the home environment, in cases of chronic residual disability. Studies of functional reorganisation of the central nervous system following injury have shown that early motor activity during rehabilitation training has a significant impact on functional recovery .Certain conditions associated with the use of robotic rehabilitation appear to particularly influence functional outcomes. Indeed, it has been observed that in long-term upper limb treatments, therapy involving high-intensity activity features with repetitive, controlled and goal-directed movements—well suited to the use of robotic devices with controlled tasks—offers a significant improvement in functional recovery compared to conventional treatments ,18.The use of robots in rehabilitation allows us not only to maximise the number of repetitions of the same exercise, which is a key element for neural pathway reconstruction, but also to adjust the contribution required from the patients so that they always work at the limit of their remaining motor skills, with an ‘assisted as needed’ approach. Finally, robotic devices used in rehabilitation typically interact with objects or immersive graphic interfaces that help patients maintain high levels of attention and engagement—other critical factors for an effective and rapid functional recovery pathway. The support needed can vary greatly depending on the residual disability of the patient’s upper limb.https://www.grandviewresearch.com/industry-analysis/rehabilitation-robots-market-report, accessed on 10 February 2023), the CAGR being the average yearly increase in revenues between two years. In commercial terms, the rehabilitation robotic market has been estimated at USD 226 million in 2021 and is predicted to grow with a Compound Annual Growth Rate (CAGR) of 17.3% from 2022 to 2030 . Consequently, an increase in DALYs measures the benefits associated with a public health intervention. The ventions . A more cost-utility analysis, instead, Quality Adjusted Life Years (QALYs), which merge quantity and quality of life [In  of life , are usecost–benefit analysis is an economic evaluation that compares the benefits and losses of an intervention with the costs associated with it [Finally,  with it . Althoug with it .In the last thirty years, the interest in cross-disciplinary frameworks, such as Health Technology Assessment (HTA), has increased. The final aim of this method is to select the most promising biomedical technologies, which can reach patients and society in a timelier fashion. HTA is the systematic assessment of the costs and multidimensional consequences of a medical technology ,25,26,27Another methodology for assessing the value of health technologies has gained acceptance: the Social Return on Investment (SROI). Unlike the cost–benefit analysis, the SROI takes into account different kinds of outcomes, associated with the triple bottom line: economic, social and environmental ,30. TherConsidering that multiple stakeholders are involved in the rehabilitation of stroke patients and that costs and outcomes cannot always be monetised, the authors applied the SROI method to build a model to assess the value of the AGREE exoskeleton from a societal perspective.To address the objective of the research, the authors applied the SROI methodology to assess the value of the AGREE exoskeleton. The model, in particular, aims at solving the failure of the traditional analytical methods, which fall short of accurately identifying all positive and negative externalities.For the proposed objective, SROI has been used as baseline methodology; environmental impacts have been accounted for through the Life-Cycle Assessment (LCA).As already described, the SROI methodology is an evolution of the cost–benefit analysis, entailing a larger definition of impact.i. Involve stakeholders; ii. Understand what changes, iii. Value the things that matter, iv. Only include what is material, v. Do not over-claim, vi. Be transparent, vii. Verify the results.SROI analysis is based on seven principles : i. InvoEvaluative, which is carried out ex post retrospectively and based on actual results that have already occurred.Forecast, which predicts the amount of social value that will be generated if the activities achieve the expected results.There are two different types of SROI : EvaluatEstablishing scope and identifying stakeholders, Mapping outcomes, Evidencing outcomes and giving them a value, Establishing impact, Calculating the SROI, and Reporting, using and embedding.The SROI method is based on the evaluation of an organisation’s activities using an input–output-outcome model with the full involvement of key stakeholders . The sixTherefore, it is first important to define the components of the analysis, in terms of objectives, background, time horizon and type of analysis. In this study, the social impact measurement of the AGREE exoskeleton was conducted with a time horizon of 5 years. The useful life of biomedical devices such as AGREE is generally considered to be between 5 and 10 years. It is hoped that AGREE will function for 10 years; however, for the purposes of the economic estimates, it was decided to be prudent and consider a useful life of 5 years. Moreover, SROI estimations are, in general, carried out considering a time horizon between 1 and 5 years , so thisThe SROI Analysis of the AGREE project was carried out as a forecast analysis. In fact, since the exoskeleton is not on the market yet, its social impact has been evaluated for the first 5 years after the launch.Then, it is important to list all the stakeholders affected by the analysed activity, to understand the changes perceived by them and to define how to involve them in order to better understand and estimate their contribution to the activity and the experienced outcomes. The identified stakeholders were: patients, hospital, physiotherapists, caregivers and employers.Involving the stakeholders is crucial to avoid autoreferentiality, subjectivity and double counting of measurements. Unfortunately, it was not possible to involve all the stakeholders identified for this analysis, but expert opinion elicitation was used to engage a pool of senior clinical engineers and healthcare professionals working in different Italian hospital settings. This methodology works to retrieve valuable information from crucial stakeholders and it is suitable when the empirical results are limited or insufficient .Then, for each stakeholder, an input–output-outcome-impact chain was developed, and inputs (both monetized and non-monetized) and outcomes were estimated. In this phase, collecting data was fundamental, and values could be established through interviews with the experts, and, when the evidence was limited, extant literature was also consulted. Attribution: the number of outcomes caused exclusively by the activity under consideration;Deadweight: a measure of the number of results that would have been obtained even without the activity;Displacement: the measure of how much an outcome has displaced other outcomes;Drop-off: measures the deterioration of outcomes over the years.In order to calculate the final social impact in a coherent and rational way, it must be verified if the outcomes calculated in the analysis could be uniquely associated with the activity under consideration. This can be achieved through the appraisal of some factors, with the aim of not overestimating the generated impact. These factors are:Finally, if the considered time horizon is more than one year, it is necessary to actualize yearly outcomes to obtain the final SROI. The discount rate that was chosen is the one suggested by the UK HM Treasury’s Green Book, since it is the most used in SROI calculations for public initiatives . The valIn the end, in every investment decision uncertainty must be considered, so it is useful to conduct a sensitivity analysis. Since the model is based on assumptions, the sensitivity analysis can be carried out by modifying one of them and verifying how the results change according to this.As a final step, the results of the analysis should be communicated and reported, explaining all the hypotheses taken into account and the followed procedure.LCA is defined as “a methodology for integrated impact assessment that quantifies the  impacts associated with the entire life cycle of products” . Definition of goal and scope: this phase defines the goal and components of the study;Inventory analysis: in this phase, the life cycle of a product is studied, and all inputs and outputs are identified;Impact assessment: in this phase, the data considered in the inventory analysis are combined with the environmental impact categories;Interpretation of results: in this final step, the results of the analysis are explained and clarified.The two main standards for conducting an LCA are UNI EN ISO 14040  and UNI EN ISO 14044 . This iterative methodology is divided into four main steps: Although there are not many applications of LCA in SROI in the literature, the authors sought to include the environmental impact using the LCA within the SROI. This approach was then applied to the AGREE case to assess its value for money. In order to understand how to comprehend environmental considerations in the SROI computation, the authors included the results of the LCA analysis carried out with Open LCA in the outcomes of the SROI, considering as a positive result the reduction in emissions and as a negative result the rise in emissions . Benefit Transfer Method. This is used when there is little evidence to evaluate non-commercial data, and reference is made to already existing studies on environmental or social benefits [The monetization of environmental impacts has been performed through the benefits .Before presenting the results of the SROI analysis for AGREE, it is important to clarify that the model is based on assumptions, which may vary from hospital to hospital. The study was made possible employing expert opinion elicitation with a pool of senior clinical engineers and healthcare professionals working in different Italian hospital settings. The SROI was calculated both for a single exoskeleton and for a number of sold exoskeletons estimated by the authors to be sold in the 5 years. (1)Physiotherapists can treat only one patient per session, both in the case of traditional therapy and in the case of robotic therapy.(2)The rehabilitation pathway for a post-stroke patient includes a total of 72 h (divided among different rehabilitation therapies). Of these, 20 h are spent on upper limb rehabilitation with traditional therapy, delivered in sessions of one hour each.(3)The robotic rehabilitation session, with equal efficacy, could result in a 33% reduction in treatment time, due to the higher exercise intensity. The upper limb rehabilitation still lasts 20 sessions, but 40 min each. The time saved (20 min) could be used for other treatments included in the rehabilitation plan, for example, speech therapy, neuropsychology, and generally better recovery of other anatomical districts.(4)1week), measured by the EQ5D3L method, was 0.584, while the QoL 4 months after stroke (QoL4months), also measured through the EQ5D3L method, was 0.694 [1week for taking into account the QoL early after stroke, and they used the value of QoL4months for considering the QoL after rehabilitation.To consider the outcomes obtained for patients, the authors used the Quality of Life (QoL) parameter. Referring to the study by Golicki and colleagues (2015), the QoL at 1 week after stroke The technology is used on both hospitalized patients and day-hospital patients. Since the likelihood of these two scenarios was unknown, it was assumed that 50% of the patients would be treated in the day-hospital, while inpatient treatment was assumed for the other 50%.(6)The rate provided by the National Healthcare System to a facility for performing robotic rehabilitation was set equal to the rate for traditional rehabilitation. This corresponds to a Diagnosis-Related Group (DRG) of 278.00 EUR/day. Then, an increase of 8% was taken into account resulting in a total of 300.08 EUR/day in order to also include complex facilities. This amount covers all rehabilitation costs for a neurological patient, including speech therapy, psychology, neurorehabilitation, lower limb rehabilitation, etc. Of all these therapies, upper limb rehabilitation represents 1/3 of the total therapy time, and consequently, 1/3 of the DRG was considered, i.e., 100 EUR per session.The analysis was carried out to have a comprehensive view of the likely impact created by the rehabilitation activity performed thanks to the AGREE exoskeleton, identifying outcomes that could be positive, negative, intended or unintended. The results reflected in this section are subject to the base case assumptions used in the model.In the following lines, a brief description of the stakeholders involved and the expected changes caused by the initiative are reported. Patients: the patients concerned are those that could be treated with the exoskeleton in the 5 years analysed. In particular, both inpatients and outpatients were considered. The impact generated on them would be undoubtedly positive since they are the direct beneficiaries of AGREE, and their recovery could be faster than with conventional therapy.Hospital: The impact on the hospitals/clinics that decide to purchase the AGREE exoskeleton would be positive, both in terms of the greater number of patients that could be treated with the new equipment and in terms of the better reputation that the institution could have from the point of view of technological progress.Physiotherapists: The service offered by the exoskeleton would help them optimize their time, increase the number of patients treated, but also increase their knowledge of robotics, which would open up new career opportunities for them.Caregivers: Rehabilitation, which increases the patients’ independence and quality of life, would have a positive impact on their families by relieving them of the burden of constant care, giving them more free time and improving their mental health.Employers: Employers of patients involved in rehabilitation were also considered. Indeed, AGREE would be a faster way for them to get their employees back to work, reduce costs associated with “sick leave,” and increase company productivity.In the following lines, a description of the inputs, outputs, outcomes and impact for each stakeholder is provided. The inputs represent the stakeholder contribution to the activity that is then transformed into outputs. Outcomes are the short-term consequences of the activity, and impacts, instead, represent the long-term consequences of the project.https://www.universitynetwork.it/ecco-quanto-tempo-trascorriamo-sui-mezzi-pubblici/, accessed on 10 February 2023) to reach a target hospital where the rehabilitation takes place, i.e., about 40 min for the outward journey and 40 min for the return. In the calculations, we considered this value as applicable both for the inpatients and for the patients treated in day-hospital. Indeed, we had no elements to calculate the time dedicated by each patient to the AGREE therapy, apart from the 40 min of duration of the session. We therefore estimated it using the same timings of the day-hospital patients. The inputs, outputs and outcomes for patients are described in Patients participate in the activity dedicating their time to performing the rehabilitation. The direct output is the patient rehabilitation that allows them to reach an improved QoL. In the long term, the impact on patients would be the participation in social activities they were previously unable to join in. In order to monetize the working hours dedicated to performing the rehabilitation, the authors estimated the time required by patients to perform the therapy with the addition of an average travel time in the city of Milan ).Then, considering 8 working hours per day, the working hours dedicated to performing the rehabilitation were monetized through the average salary in Italy  that, since it is not a stable value, was increased by 2% every year, and the mean of marginal costs of the main Italian providers.There are two inputs for hospitals: The outcome for the hospitals was represented with the increased number of therapies that they can perform thanks to the usage of AGREE. Since the duration of the single therapy session can be reduced by 33.3%, more patients can be treated in the remaining time. The number of increased sessions, then, can be multiplied by the DRG value of EUR 100.08. The inputs, outputs and outcomes for hospitals are described in More time to be dedicated to new patients: this was calculated considering the time saved for each therapy and multiplied by their net average salary.Physiotherapists involved in the AGREE rehabilitation process need to complete about 7 h of training to use the exoskeleton in the proper way. To monetize this outcome, the average gross salary of four physiotherapists has been considered as a reference number correspondent to the cost sustained by a target hospital.The input considered for physiotherapists was their workforce, calculated as their net average hourly wage (17 EUR/h) multiplied by the AGREE working hours/day (7 h/day) multiplied by 275 days/year. Here, it was not considered that physiotherapists are always working with the exoskeleton, but that for the 7 h/day in which AGREE works, a physiotherapist assists the patient with it. The direct output is patient rehabilitation, with three different types of outcomes identified: As a long-term impact, the use of AGREE, and of robotic rehabilitation in general, would boost their growth as professionals. The inputs, outputs and outcomes for physiotherapists are described in https://www.contratticcnl.it/, https://www.lebadanti.it/blog/stipendio-colf-e-badanti-2022-tabelle-dei-minimi-retributivi-e-livelli-dinquadramento/ accessed on 10 February 2023).Time lost to support the patient during the rehabilitation activity: the working time spent by caregivers to bring the patient to target the hospital/clinic, to wait for the patient to finish the rehabilitation session and to come back home. For the travel time, it can be considered the one already assessed for the patient input computation. Finally, this input has to be calculated only for the caregivers of the outpatients . To monetize this input, the average salary of a caregiver has been used. Caregivers were considered in the Italian D super level, characterized by family assistants of non-sufficient people, with an average salary of 9.24 EUR/h .Making a parallelism with the QoL, a patient with a QoL of 1  corresponds to a disability equal to 0%. Considering the QoLThe long-term impact would consist of the caregivers’ social and work reintegration, which would be beneficial to them lowering their psychological stress. The inputs, outputs and outcomes for caregivers are described in For the employers, no input was considered. Regarding the outcome, since an employee in Italy can request a maximum of 6 months of sick leave, it has been assumed that the improvement in the QoL could allow them also to require fewer days of sick leave, proportionally to the improvement in QoL, which is around 19%. For the employers, these represent re-employed hours, and so they are monetized with the average employee salary. The inputs, outputs and outcomes for employers are described in First of all, the deadweight has been estimated particularly making reference to the assumption that traditional rehabilitation is 66.6% effective compared with robotic rehabilitation. This was applied to all the outcomes except the outcome related to the QoL since it was considered equivalent to the one obtained through robotic rehabilitation. Regarding attribution, instead, it corresponds to the responsibility of activities for the outcomes. However, since in the evaluation of the outcomes it was always considered only the value created by the robotic rehabilitation through AGREE, a coefficient of 100% was applied. The drop-off, finally, is related to the duration of the equipment. A diffused method of considering the drop-off is to deduct a fixed percentage for each year of the project duration . In thisThis section reports the results of the environmental impact assessment of AGREE. Being AGREE in development, the main difficulty in this evaluation was the availability of reliable data.The authors, first of all, mapped all the lifecycle processes of AGREE, including the phases from development use, disposal and recycling and performed an inventory analysis describing all the flows associated with the different processes. The assembly and disposal phases were distributed over the 5-year life of the exoskeleton. Having at disposal all the technical data regarding AGREE’s components, it was possible to create a bill of materials. The calculation of the environmental impact also took into account the electricity consumption, as described above, together with the accompaniment of patients carried out by caregivers. Regarding the disposal and recycling processes, two main processes were considered as reference for the disposal of mechatronic devices: manual disassembly and shredding/mechanical separation. Then, every component of AGREE was considered either disassembled manually, or shredded/separated mechanically. At the end of these processes, the raw materials can be recycled or incinerated, generating electricity. In terms of recycled materials, the recyclability percentage is associated with an avoided impact, i.e., the production of new material that can be avoided by using recycled materials. 2 equivalents: they were equal to 2233.09 kgCO2e/year.To perform the impact assessment of LCA, the authors chose to analyse the impact category “climate change”, and the IPCC 2013 was used as a characterization model. As a result of LCA, the authors obtained the emissions caused by all the lifecycle processes, in terms of CO2 emissions, it was considered a cost of 0.116 EUR/kgCO2e . In order to monetize these COThe final value of the AGREE environmental impact is equal to 259.04 EUR/year, where the most relevant phase in terms of environmental contribution is the use phase. Having calculated all the economic, social and environmental outcomes, it was possible to calculate the final SROI. In particular, four values of the SROI will be reported: the SROI computed for one exoskeleton, the SROI computed for the number of exoskeletons projected to be sold, and both with and without the environmental impact. The SROI values are shown in For carrying out the sensitivity analysis, the SROI was calculated by varying two parameters. The first one, which was particularly relevant for the calculation, is the QoL. In this study, the increase in QoL of 19% was considered equal for robotic and traditional rehabilitation. Of course, by varying this assumption, results change; the authors decided to vary the QoL after rehabilitation of ±5 percentage points (pp), to see how the results could change. Improving the QoL of 14%, instead of 19%, the results are reported in the Improving the QoL of 24%, instead of 19%, the results are reported in The second parameter that was changed for conducting the sensitivity analysis was the discount rate, to verify the extent to which the social validity of AGREE would change in relation to changes in the discount rate. To do this, we decided to increase the discount rate from 3.77% to 5%, and the results are reported in the This study sought to develop a model to assess the social and environmental impact of healthcare technologies, with a focus on an exoskeleton for upper limb rehabilitation developed by a team of researchers at Politecnico di Milano. We decided to employ the SROI methodology, being able to embrace various typologies of impact, and to also include in the SROI calculations an LCA analysis for assessing the environmental impact of the considered technology.The final SROI value resulted largely over 1:1 for all the considered cases, meaning that AGREE can be considered worthy of investment. The first thing that can be pointed out is the fact that considering the forecast sales the index decreases with respect to the SROI calculated for the single exoskeleton. This can be explained by the fact that outcomes are calculated in a cumulative way: by increasing the number of exoskeletons sold during the years, the outcomes increase but so too do the inputs associated with the purchase and use of these exoskeletons. However, the SROI calculated for multiple exoskeletons still remains high. Another important aspect to be analysed is the low relevance of the inclusion of the environmental assessment in the SROI computation. Indeed, this is connected to the fact that a rehabilitation exoskeleton is largely not environmentally damaging technology, while, as evident from the results, it is able to create a great social impact. However, the authors have contributed to provide an indication of how the environmental impact can be included in the SROI calculations. Since for other types of technologies or drugs it might give very different results, it should be a good practice to consider it in these evaluations.It should also be taken into account that, although the sum of benefits exceeds the sum of costs, the distribution of benefits and costs may differ between different stakeholders. In particular, patients have more benefits than other stakeholders, even if they do not pay for their rehabilitation, which is guaranteed by the universal public health care system. The SROI methodology does not take into account this difference in the nature of benefits and costs. However, an increase in benefits for patients is reflected in an increase in benefits for their caregivers, their employers, and, thus, for the society as a whole. Thus, patients are not the payers of their rehabilitation, but this should not be an obstacle to the adoption of this technology, since their improvement represents a long-term benefit to society as a whole. Finally, the authors conducted the sensitivity analysis by increasing or decreasing the improvement of QoL by 5 pp. This is because two scenarios can be taken into account. Firstly, the QoL of patients treated with AGREE results higher than the QoL of patients treated with traditional rehabilitation. In this case, the SROI would be much higher, reaching a value around 4.6:1 for the single exoskeleton and 3.5:1 for multiple exoskel-etons. Second, another possibility could be that robotic rehabilitation, contrary to what experts and authors assumed, may have worse outcomes than traditional rehabilitation. This would be a negative result for this study, but, as the sensitivity analysis reported, the SROI would always remain higher than 1. Additionally, performing the sensitivity analysis by varying the discount rate from 3.77% to 5%, the SROI remained largely higher than 1, proving that the value of this technology would remain high even considering variations in the discount rate.This paper contributes to research both from a theoretical and a practical point of view. This paper provides a model that merges the SROI methodology with the LCA. Even if the results were not particularly different considering or not the LCA analysis, other results could be obtained if the model were applied to other technologies. Moreover, this research enlarges the number of SROI studies applied to the healthcare field. From a practitioner’s point of view, this model could be used by decision-makers for assessing the value of robotic rehabilitation. Assumptions can be varied from case to case, but it offers a reference framework for conducting this type of evaluation. Finally, this investigation has also some limitations: first of all, subjectivity. Subjectivity is typical of SROI calculations, but may also be related to the fact that AGREE is still in development, and therefore, only preliminary information is available. Subjectivity can be solved through stakeholder involvement, and expert opinion elicitation contributed in this sense. However, it would be greatly useful also to interview patients and caregivers, and this can be a future research direction. Subjectivity is inherent also in the LCA analysis, since the choice of the impact category and of the monetization method can differ from analyst to analyst. In addition, the model is based on assumptions, and is therefore subject to uncertainty. The number of patients tackled by the technology is based on a strong assumption, as well as the QoL is based on a previous study but it could vary. In the future, these values could be refined, by interviewing all the stakeholders involved in the process and precisely evaluating all inputs and outcomes.The results obtained from the application of this model satisfied the research objective of this research, and the AGREE technology resulted in being value for money.This research provides the application of a model to a specific technology; however, it could also be generalized and employed for evaluating other kinds of technologies. The SROI analysis returns a number that is easy to be comprehended and compared to other cases. This study was not limited to assessing the economic value of this biomedical technology, as cost–benefit analyses might do. Rather, it attempted to evaluate the economic, social and environmental consequences of one healthcare technology, resulting in a model that could be used in decision-making processes. The SROI, coupled with the LCA, proved to be a good method to assess the extensive impact of a technology on society as a whole.Future developments of this research include the possibility of involving more stakeholders in the analysis, in order to broaden the perspectives and reduce the uncertainty of the study.


Differences based on gender in the presentation and outcome of many psychiatric conditions have been highlighted in the past years. Moreover, women are often underrepresented in research samples, thus leading to a poorer understanding and addressing of their needs. As regards psychiatric rehabilitation, few studies have focused on the influence of gender on the outcomes of rehabilitation programs.This study aimed to analyze the impact of gender on socio-demographic and clinical characteristics, as well as on main rehabilitation outcomes, in a sample of subjects undergoing rehabilitation programs in a metropolitan residential service.t-test and chi-square for continuous and categorical variables, respectively.We collected socio-demographic, clinical variables and rehabilitation outcomes of all subjects discharged from the metropolitan residential rehabilitative service of the Luigi Sacco Hospital in Milan, Italy, from January 2015 to December 2021. Gender differences were analyzed through In a total sample of 129 subjects equally distributed for gender (50.4% women), all subjects improved after their rehabilitation program, as measured through specific psychometric scales. However, women had a higher proportion of discharges to their own household (52.3% vs. 25% of men). They also showed higher educational status (53.8% completed high school vs. 31.3% of men). Clinically, they showed longer duration of untreated illness (3.6 ± 7.31 vs. 1.06 ± 2.35 years) and lower frequency of substance use disorders compared to men (6.4% vs. 35.9%).The main result of this study shows, in light of an equal improvement in psychopathological and psychosocial functioning after the rehabilitation program, better outcomes in women compared to men, with a higher frequency of return to their own household after the completion of a rehabilitation program compared to men. It is well known how many diseases can present differently between women and men. Nonetheless, gender-specific research that could aid to better identify and treat many conditions still represents a small portion of literature. Moreover, understanding gender differences can support the individualization of care, which is gaining huge importance in modern medicine. As regards psychiatric disorders, gender has been shown to influence prevalence, presentation, course of disease, comorbidities and response to treatment of many diseases .However, many social, economic and cultural differences between men and women can influence and be influenced by clinical presentation, response to treatment and recovery . As an eFocusing on these differences is crucial when considering that, for psychiatric disorders, remission of clinical symptoms alone is rarely associated with recovery , 10. TheThe concept of recovery has been widely discussed in the psychiatric field and is becoming the main target of psychiatric care in many healthcare models –15. HoweMental health rehabilitation services focus on those with more severe and complex mental health problems and have been pioneers in adopting recovery based practices –20. PsycMany studies focused on the efficacy of psychiatric rehabilitation in aiding patients to gain functional recovery –27. In tHowever, one of the main challenges in the development of optimal rehabilitation models, is the difficulty in identifying and standardizing outcome measures of rehabilitative programs; objective measures of improvement in psychopathological, relational and social functioning are needed , 36–38. Moreover, few studies focused on the identification of factors influencing rehabilitation outcomes, and even less focused on the influence of gender on rehabilitation outcomes. In one study, Cook analyzed data from 650 subjects who carried on rehabilitation programs in a psychosocial rehabilitation center in the US . ConsideIn light of the paucity of data on the influence of gender on rehabilitation outcomes in psychiatry, we aimed to study gender differences in a sample of subjects undergoing community-based rehabilitation programs in Milan, focusing on the possible different outcomes between the two genders.This retrospective observational study aimed to evaluate the impact of gender on socio-demographic and clinical characteristics and on rehabilitation outcomes of residential patients carrying out rehabilitative programs at the High Assistance Rehabilitation Community (HARC) of the “Luigi Sacco” University Hospital, belonging to the Department of Mental Health and Addiction of the ASST Fatebenefratelli – Sacco, Milan, Italy. The HARC provides continuous residential assistance to patients with major psychiatric disorders who voluntarily accept to undergo a rehabilitation program. The study protocol was approved by the Department of Psychiatry of the ASST Fatebenefratelli-Sacco of Milan as relevant institutional review board for low-risk studies.All patients must be previously taken in charge at a territory-based psychosocial outpatients service responsible for continuity of care, which is also responsible for requesting admissions to HARC. Patients can undergo two different residential rehabilitative programs: the Post-Acute (RPA), 3 months program, renewable up to 6 months, and the High Intensity (RHI), 18 months program, extendable up to 24 months.Patients who are admitted to the HARC undergo a psychopathological and psychosocial functioning evaluation before identifying and planning, in accordance with the patient preferences, individualized goals within the personalized therapeutic rehabilitation pathway. Activities involved in rehabilitation programs are individual and group occupational projects, psycho-educational interventions, cognitive remediation programs, social skills training, expressive and psychotherapeutic activities, all of which aiming to develop and improve personal, social, relational and work-related skills. Every patient is offered an individualized program of activities tailored to their rehabilitation needs, informed by their psychosocial and functional assessment.The evaluation of psychopathological status and psychosocial functioning is made through specific scales: Kennedy Axis V , 41, froMedical records of all residential HARC patients discharged between January 2015 and December 2021 were retrospectively reviewed, in accordance with hospital privacy rules, by authorized personnel in order to collect pseudoanonymized, clinical, socio-demographic and therapeutic data. Collected variables were: gender (used to stratify the sample), age at admission, educational status, housing and work condition at admission, psychiatric diagnosis, presence of dual diagnosis, organic comorbidities , age at onset and at first psychiatric treatment, duration of illness and duration of untreated illness, previous rehabilitation experiences both lifetime and in the 12 months before admission, number of hospitalizations lifetime, place of origin at the time of admission , reason of admission, type of rehabilitation program (RPA vs. RHI), length of rehabilitation program (months), hospitalizations during the project, destination after the program, scores of the previously mentioned scales at both admission (T0) and discharge (T1).The change in the scores between T0 and T1  and the destination of the patient after the program  are considered outcome measures of the rehabilitation program. Dropouts have been identified in both those patients who voluntarily interrupted the rehabilitation program before its end, and in those who have been discharged beforehand because of non-compliance to the rules of the community.t-test have been used for categorical and continuous variables, respectively. A paired-samples t-test has been carried out to analyze the change in the scores between T0 and T1, in the total sample and in the two subsamples based on gender. Statistical analyses were performed with SPSS software, version 26. Statistical significance has been set at value of p < 0.05 for all analyses.Categorical variables are presented using frequencies and percentages, while continuous variables are presented as mean and standard deviation (SD). Gender has been used to stratify the sample and compare variables between subjects. Chi-square test with Bonferroni post-hoc analysis and Student The final sample included 129 subjects discharged from the HARC between January 2015 and December 2021. The distribution between genders was almost 1:1 . Socio-demographic and clinical characteristics of subjects in the total sample and their comparison between genders are shown in p < 0.05).For the majority of socio-demographic variables, women and men showed similar distribution. However, a significantly greater proportion of women reached a higher educational status before admission, with 35 (53.8% of women) of them having a high school diploma, compared with 20 (31.3% of men) men , while between men a significantly greater proportion of subjects presented a dual diagnosis, with 23 (35.9% of men) of them presenting a co-occurring substance use disorder diagnosis compared with 4 (6.2% of women) women.As regards clinical characteristics, women showed a slightly longer duration of untreated illness  women vs. 26 (40.6%) men].In terms of rehabilitation outcome measures, identified both as a change in the scores of Kennedy Axis V, BPRS, AR-VADO and GAF scales between T0 and T1 and in the destination at discharge after a rehabilitation program , no diffThe aim of this study was to determine whether gender might influence the outcomes of psychiatric rehabilitation, analyzing its relationship with main socio-demographic, clinical and rehabilitative characteristics in a sample of subjects who carried on rehabilitation programs at the HARC, a high intensity and post-acute rehabilitation community in the metropolitan area of Milan.One outcome measure analyzed consisted in a change of main psychopathological and functional scales scores from T0 to T1. In our sample, we found a statistically significant improvement in all scales at T1, regardless of gender. In a general perspective, this result confirms the efficacy of the individualized rehabilitation programs carried on at the HARC. Of note, no difference was found in the T0 scores of psychosocial and psychopathologic scales of female and male subjects, therefore the two subsamples could be considered comparable,The second outcome measure consisted in the destination at discharge from the community. Destination at discharge is influenced by various factors, mainly the level of independence achieved during the program, the successful stabilization of symptoms and the acquisition or improvement of social, relational and work-related skills . The impMany studies in the literature confirm the similar levels of improvement in functioning between the two genders, as measured by psychometric scales, regardless of destination at discharge , 48. In Even though the higher number of women discharged to their own household is in line with previous findings , we did Moreover, many studies focused on the higher probability for women to develop social skills and build social and sentimental relationships before the onset of a psychiatric disorder, especially in the psychotic spectrum , 48–50. Another reason for this difference could lay in the higher frequency of dual diagnosis found in the male subsample, which could have influenced both functioning and the possibility to return to one’s own household. The higher number of men reporting a substance use disorder is in line with previous findings , 50, 51.Lastly, in our sample women showed a longer duration of untreated illness compared to men. This result is in contrast with previous data, that underline how women usually refer to psychiatric services earlier and with higher adherence compared to men . Such fiIn our study, we aimed to analyze potential gender differences in the outcomes of rehabilitation programs of a rehabilitative community in Milan. Our main result showed how more women are discharged to their own household after a rehabilitation program, compared to men. This result is in line with previous literature, and might reflect a higher level of baseline functioning in women, which usually develop more social and relational skills before the onset of the disease. However, through the use of validated psychometric scales for the evaluation of psychosocial and psychopathological functioning both at admission and discharge, no major difference between men and women was found, and an overall improvement in functioning characterized the sample.This study has several strengths, such as the relatively large sample of subjects included and the thorough submission of validated psychometric scales to all subjects. However, one limitation of the study lays in the lack of reliable data about patients’ baseline levels of functioning, i.e., before the acute episode or condition that required admission to the rehabilitative community. In fact, our results and previous findings in literature suggest different levels of functioning in female and male subjects with psychiatric conditions. Moreover, influence of previous traumatic events  on psychopathological functioning has not been included in the present research, in order to keep the focus on gender alone. However, we must acknowledge the greater frequency of such events in the female gender, and therefore the importance of including these data in future studies. Lastly, our research did not focus on characterizing subjects who showed worse rehabilitation outcomes, therefore no hypothesis on which specific features might be more directly related to improvement during rehabilitation can be drawn from our study. Further research focusing on gender-specific and rehabilitation psychiatry is needed, in order to aid mental health services to implement preventive and supportive activities for the acquisition and improvement of specific skills associated with higher probability of independent living.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors acknowledge support from the University of Milan through the APC initiative.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. 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Telementorship provides a way to maintain the professional skills of isolated rural health care workers. The incorporation of augmented reality (AR) technology into telementoring systems could be used to mentor health care professionals remotely under different clinical situations.This study aims to evaluate the usability of AR technology in telementorship for managing clinical scenarios in a simulation laboratory.This study used a quasi-experimental design. Experienced health professionals and novice health practitioners were recruited for the roles of mentors and mentees, respectively, and then trained in the use of the AR setup. In the experiment, each mentee wearing an AR headset was asked to respond to 4 different clinical scenarios: acute coronary syndrome (ACS), acute myocardial infarction (AMI), pneumonia severe reaction to antibiotics (PSRA), and hypoglycemic emergency (HE). Their mentor used a laptop to provide remote guidance, following the treatment protocols developed for each scenario. Rating scales were used to measure the AR’s usability, mentorship effectiveness, and mentees’ self-confidence and skill performance.P=.001 for the ACS, AMI, and PSRA scenarios and P=.002 for the HE scenario). Mentees’ individual skill performance rates ranged from 98% in the ACS scenario to 97% in the AMI, PSRA, and HE scenarios.A total of 4 mentors and 15 mentees participated in this study. Mentors and mentees were positive about using the AR technology, despite some technical issues and the time required to become familiar with the technology. The positive experience of telementorship was highlighted . Mentees’ confidence in managing each of the 4 scenarios improved after telementoring (This study provides evidence about the usability of AR technology in telementorship for managing clinical scenarios. The findings suggest the potential for this technology to be used to support health workers in real-world clinical environments and point to new directions of research. Many rural and remote areas experience a shortage of care professionals . The lacThe use of telementorship to provide professional support and overcome the geographical barrier of distance has increased. Through telementorship, a medical expert can provide instructions remotely to a novice practitioner at the treatment site in real time . AdvanceAugmented reality (AR) is an immersive experience in which the real world is enhanced by computer-generated, 3D content tied to specific locations or activity tasks -15. The Very few studies have assessed the application of AR technology in which a mentor guides a mentee to manage complex clinical scenarios. This study aimed to address this gap.This study aimed to evaluate the usability of AR technology in telementorship for managing clinical scenarios in a simulation laboratory. The objectives of this study were as follows:Assess mentors’ and mentees’ perceptions of the usability and effectiveness of AR technology for telementorshipEvaluate changes in mentees’ self-confidence and skill performance in the management of clinical scenarios when mentored using AR technology.A pragmatic quasi-experimental design was used in this study. A total of 4 mentors and 15 mentees were included in this study. The study protocol was previously published  and provThe AR telementoring setup comprises a mentor station and a mentee station, as illustrated in The mentor station had a Dell Latitude 5490 laptop. The laptop had a screen size of 14 inches, a screen resolution of 1920×1080 pixels, processor type Intel Core i5-8350U, RAM of 16 GB, and Windows 10. The laptop was connected to a touchscreen, a computer mouse to facilitate annotation, and a headset with ear pads and a noise-canceling microphone to block out ambient noise. The Microsoft Teams software  and PSRA [IQR 2.20-3.40]) to 3.40 (ACS [IQR 3.00-4.00]).P>0.5). The median posttest scores in general confidence were at a high level  in all the scenarios.The mentees appeared significantly more confident in the simulation environment and in using the AR technology immediately after each scenario performance  and under observation or remote instruction via the HoloLens during the call. These data were subjected to the Wilcoxon signed rank test, with the results showing statistically significant gains in all skill groups in all 4 scenarios P<.001; .During the simulation sessions, various prompts were used through 60 times of scenario performances with voice (833 times), visual , and annotation (47 times). Regarding the 5 practical skill groups, the mentors used voice and visual prompts the most to instruct the mentees in the patient examination  and medication administration . All annotations were applied in the patient examination. The voice and visual prompts were used together 87 times, whereas visual prompts were inserted into the mentees’ view 17 times without explanation. The mentees commented that the usefulness of visual prompting allowed them to extend their practice capability, which would not have been possible without the HoloLens.To assess the mentees’ skill performance, a checklist was taken from the developed scripts of the clinical scenarios. The score for each item is as follows: 0=“did not perform,” 1=“inaccurately performed,” and 2=“accurately performed.” The average scores of the mentees’ performances in each scenario were 37.31 (SD 1.702) out of 38 (ACS), 44.6 (SD 2.530) out of 46 (AMI), 36.73 (SD 1.624) out of 38 (PSRA), and 44.43 (SD 1.785) out of 46 (HE). Thus, the average of individual performance rates, which are calculated by dividing the average score by the maximum score, ranged from 98% (ACS) to 97% .The study recorded the extensive period using HoloLens with all 7 core AR features for remote assistance across all 4 contemporary emergency clinical scenarios. The generally positive perception of mentees and mentors was reported, and technical issues were noted.From the clinical point of view, the application of AR technology through clinical scenarios provided evidence of its usability far beyond the studies on a single clinical procedure. For instance, the participants in the study by Ingrassia et al  used theThe AR annotation offered by the HoloLens in the AR setup enabled the mentors to provide the mentees with better remote instruction and increased performance. In this study, our mentors used annotation to instruct the mentees on abnormalities on electrocardiograms, chest x-rays, and patient monitors. Such use was slightly different from the investigation by Rojas-Muñoz et al , where tFurthermore, the AR setup features reference insertion and electronic database access, potentially making the HoloLens a daily tool in operating rooms or COVID-19–related clinics when it is vital to keep the surgical theater sterile or limit the risk of virus transmission by minimizing direct contact ,39. ThesAlthough version 2 of the HoloLens has nearly double the field of view compared with version 1 , it remains the main limitation contributing to increased cognitive load on the users. The narrow field of view of the device made it difficult for mentors to see the whole scene while mentees were performing clinical procedures on patients. The mentees had to exert more mental and physical effort to compensate for this limitation. This finding is consistent with the findings of Baumeister et al  and IngrThe effectiveness of the mentorship was evident statistically. The satisfaction with 2-way communication using AR technology was also highlighted. The AR setup satisfactorily filled the gap in the long physical distance and created the relationship between the mentors and mentees during the simulation sessions.Findings about the quality of the situational telementorship in this study coincide with those of other studies on long-term relationships in the health care sector. Dimitriadis et al  investigOur study also found a remarkable disparity in mentor satisfaction compared with other studies. Although all mentors in this study were happy with their mentees, the mentors in the study by Lee et al  expresseThe results clearly showed the self-confidence the mentees gained after performing clinical scenarios in the simulation sessions. The statistically significant improvement in their self-confidence reflected that the telementorship using the AR setup could increase confidence, even in those who were already quite confident in skills with which they were familiar. A randomized controlled trial investigating an optical see-through AR head-mounted display reported similar findings . The stuThe confidence improvement reported via AR-based telementoring systems in this study was consistent with the studies on virtual reality (VR)–based systems or face-to-face training. For example, Chowriappa et al  validateDespite the mentees being novices, the remote assistance provided by the mentors via the AR setup supported them to perform accurately the practical skills required, with an average individual performance rate of >96% across the scenarios. The absence of a control group and pre-experimental assessment make this study inconclusive as to whether the AR-based telementoring system improves the performance of practitioners. Other studies have also provided relevant evidence. Recent literature demonstrates that the HoloLens 2 can be successfully used in a medical ward, especially during the COVID-19 pandemic ,39,48. LThis study demonstrates the use of an AR device (HoloLens) in clinical practice, similar to recent AR-related studies ,39. It iThis study has some limitations. Similar to recent AR studies in health care ,49, the This research addresses the gaps identified within the existing professional support literature, using a pragmatic approach to explore the usability of AR in situational telementorship in managing clinical scenarios. It provides insight into the experience of HoloLens use, contributing to the existing body of AR literature and providing guidance for policy and practice. There are four key findings: (1) mentors’ and mentees’ positive perception and usability of the AR setup, (2) mentors’ and mentees’ positive perception and effective telementorship, (3) significant improvement in self-confidence among mentees, and (4) high individual skill performance ratings of mentees.On the basis of these findings and the experience of the research team, the following is recommended:Further investigations to explore the advantages and disadvantages of the application of AR technology to improve health outcomes, remote assistance, and service delivery.Further investigations to explore patients’ perception and acceptability of the AR technology and headsets during a clinical visit, as they are the focus of care delivery.Comparison with other telecommunication systems or devices  to determine the actual benefits of AR.Considering design standards and licensing requirements for mentors involved in situational telementorship.Developing policies and standardized treatment procedures for advanced telecommunication technologies that will ensure patient and staff safety, personal information confidentiality, and management purposes.


Tacrolimus is the backbone drug in kidney transplantation. Single nucleotide polymorphism of Multidrug resistant 1 gene can affect tacrolimus metabolism consequently it can affect tacrolimus trough level and incidence of acute rejection. The aim of this study is to investigate the impact of Multidrug resistant 1 gene, C3435T and G2677T Single nucleotide polymorphisms on tacrolimus pharmacokinetics and on the risk of acute rejection in pediatric kidney transplant recipients.Typing of Multidrug resistant 1 gene, C3435T and G2677T gene polymorphism was done using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) for 83 pediatric kidney transplant recipients and 80 matched healthy controls.In Multidrug resistant 1 gene (C3435T), CC, CT genotypes and C allele were significantly associated with risk of acute rejection when compared to none acute rejection group . The required tacrolimus doses to achieve trough level were significantly higher among CC than CT than TT genotypes through the 1st 6 months after kidney transplantation. While, in Multidrug resistant 1 gene (G2677T), GT, TT genotypes and T allele were associated with acute rejection when compared to none acute rejection . The required tacrolimus doses to achieve trough level were significantly higher among TT than GT than GG genotypes through the 1st 6 months after kidney transplantation.The C allele, CC and CT genotypes of Multidrug resistant 1 gene (C3435T) and the T allele, GT and TT genotypes of Multidrug resistant 1 gene (G2677T) gene polymorphism may be risk factors for acute rejection and this can be attributed to their effect on tacrolimus pharmacokinetics. Tacrolimus therapy may be tailored according to the recipient genotype for better outcome.The online version contains supplementary material available at 10.1186/s13052-023-01469-w. Kidney transplantation (KT) is the optimal treatment option for children with end stage kidney disease (ESKD) . It provDespite of advancement in the field of KT; the long-term graft outcome is not yet favorable in pediatric population, due to associated complications as recurrent infections, acute rejection (AR), poor adherence to immunosuppressive (IS) drugs and transplant glomerulopathy (TG) , 3.The incidence of AR has decreased with availability of potent IS drugs, but it is still a major risk of early graft dysfunction and late allograft loss . AR can MDR-1) gene which is also referred to as ATP Binding Cassette (ABC) transporters, located on chromosome 7q21, comprises 28 exons and encodes for Permeation glycoprotein (P-gp). P-gp acts as a membrane efflux pump transporting several molecules through the cell membrane of various epithelial, endothelial cells and lymphocytes [Tacrolimus (TAC) is the cornerstone of most IS regimens with a characteristic narrow therapeutic window . Althougphocytes .Single nucleotide polymorphisms (SNPs) are the most frequently inherited genetic variations among people that occur frequently, every 100–300 bp (bp) . SeveralThe first defined mutations of MDR1 gene were G2677T/A, C3435T and G2995A . C3435T,The associations between MDR1 genotype and the pharmacokinetics of TAC remain unclear. Although, It was concluded from some studies that significant differences in TAC trough level exist between different MDR1 genotypes , 20. NevIt has been demonstrated that, linkage disequilibrium (LD) between C3435T polymorphism in exon 26 and G2677T in exon 21 may contribute to functional alteration rather than the effect of single haplotype variation . Interes(MD.20.02.283) and by Pediatric Nephrology Unit, Pediatric Department, Faculty of Medicine, Cairo University.This is a cross sectional, case control study that included 163 participants; 83 pediatric KTRs and 80 healthy controls. Pediatric KTRs were recruited during their follow up at Kidney Transplantation Outpatient Clinic, Cairo University Children Hospital . Age and sex matched healthy controls were recruited during their routine checkup at General Pediatric Outpatient Clinic. The study was conducted over two years . An informed consent for enrolment in the study was obtained from the legal guardians of all participants. The protocol of the study was approved by Mansoura Faculty of Medicine Institutional Research Board Patients were enrolled into the study according to the following criteria: (a) recipients of living donor kidney transplant (b) aged between 2 and 18 years (c) receiving TAC as a part of their maintenance immunosuppressive protocol (d) following up for at least two years after KT. Patients who received cyclosporine as maintenance therapy, had irregular follow up visits, transferred to adult service or refused to be enrolled in the study were excluded from the study as in Fig. The included KTRs (n = 83) were divided into 2 groups: (1) AR group (n = 36): KTRs with one or more of AR episode experienced during their follow up and (2) None AR group (n = 47): KTRs with stable graft function (SGF) for at least two years after KT. AR was defined as rise in serum creatinine of 20–30% from baseline levels and confirmed by pathological evidence of immune mediated graft damage that can occur at any time posttransplant, but more commonly in early postoperative months . All rejAs regard the centre policy for treatment of AR, all cases started treatment with 3 IV pulses of methylprednisolone (150–250 mg/m2/dose), initiated even prior to graft biopsy and followed by rapid tapering of oral steroids to or just above the maintenance dose. Further treatment of AR was determined according to the pathological findings in allograft biopsy: a) Anti-thymocyte globulin (ATG) was given in all steroid resistant acute TCMR that was defined as no response within 5–7 days after the first dose .b) options for acute ABMR included plasma exchange (PEX), intra venous immunoglobulins (IVIG) and anti-CD20 monoclonal antibody (rituximab) .Basic data were collected at enrolment in the study including: age, sex, original renal disease either congenital anomalies of kidney and urinary tract (CAKUT) or non CAKUT . CAKUT iAll KTRs received antibody induction therapy (either antithymocyte globulin (ATG) or Basilximab) and were maintained on TAC based triple IS regimen together with prednisolone and mycofenolate mofetile (MMF) according to the adopted protocol . Only onTacrolimus was started at a dose of 0.15 mg/kg/day in 2 divided doses and then the dose was adjusted according to the trough level measured before the next dose. The accepted trough level in our protocol is 10–12 ng/ml in 1st month and 8–10 ng/ml till 3 months, 7–8 till 6 months and 6–7 till the end of the first-year after KT [MDR1 SNPs were analyzed by the polymerase chain reaction-restriction fragment length polymorphism (PCR–RFLP) method using the following primers: For C3435T, we used forward primer 5´ - GATCTGTGAACTCTT GTT TTCA − 3´ and reverse primer 5´ - GAAGAGAGACTTACATTAGGC − 3´. For G2677T, forward primer 5’-TACCCATCATTGCAATAGCAG-3’ and both 5’-TTTAGTTTGACTCACCTTGCTAG-3’ and 5’-TTTAGTTTGACTCACCTTTCTAG-3’ were used as reverse primers. [MDR1, C3435T SNP, is composed of C and T alleles, C is the ancestral allele. . MDR1, Gprimers. . ReactioStudent T test was used for parametric quantitative variables and Mann Whitney Test (U test) was used to for non-parametric variables. The Kruskal-Wallis test was used to compare none parametric variables, between multiple studied groups. Chi-Square test was used to examine the relationship between two qualitative variables and Fisher’s exact test was used to examine the relationship between two qualitative variables when the expected count is less than 5 in more than 20% of cells. Odds ratio (OR) and 95% confidence interval (CI) were calculated to estimate the strength of the associations. The genes variants under investigation were evaluated for deviation from Hardy–Weinberg equilibrium (HWE) by comparing observed and expected genotype frequencies in control groups. Kaplan–Meier test was used for survival analysis and the statistical significance of differences among curves was determined by Log-Rank test.The SPSS software  was used for analysis of data. Quantitative data were presented in mean and Standard Deviation (SD) or median and interquartile range (IQR). Qualitative data were presented as number (N) and percent (%). P value ≤ 0.05 was considered to be statistically significant. To compare between 2 studied groups, (p = 0.06 and 0.6 receptively). The mean age of KTRs at time of KT was 9.3 ± 2.9 years, with a median post-transplant follow up duration of 5 years and male to female ratio was 3.6. CAKUT represented 50.6% of original kidney disease. Pre-emptive KT was performed in 4 patients (4.8%), while 95.2% of cases required hemodialysis prior to transplantation. Preemptive plasma exchange (PE) was indicated in 15 patients (18.1%) due to sporadic FSGS as center policy [The study overall included 163 subjects; 83 pediatric KTRs and 80 age / sex matched healthy controls r policy . DemograPatients with AR n = 36) were diagnosed pathologically as ABMR in 38.9%, TCMR in 50% and Mixed rejection in 11.1% of patients. The median duration of post-transplant follow-up duration was 60 months with interquartile range (IQR) (36–93 months). The onset of AR was early (in 1st 3 months post-transplant) in 9 cases and delayed (between 3 and 14 months post-transplant) in the remaining 27 cases. Median TAC trough level at time of AR was 5 with median TAC dose of 0.14 mg/kg/day. Pulse methyl prednisone was the first line antirejection therapy received by all AR cases with further therapy depending on the pathological type of AR. Patients with ABMR received PEX, rituximab (RTX) and IVIG while ATG received mainly by patients with TCMR. Fortunately, 52.8% of cases had complete response, 38.9% achieved partial response, and only 8.3% did not achieve any response. Complete response was defined as return of serum creatinine after treatment to 25% or less above the basal creatinine, partial remission was considered if creatinine remained 25–75% above basal level and no response if none of the above mentioned definitions was fulfilled [ were dia. Moreover; AR group had more frequent CC, CT genotypes and C allele than healthy controls . However, no significant difference was observed in the frequency of either genotypes or alleles between the None AR group and healthy controls (p > 0.05).The MDR1, C3435T and G2677T genotypes and alleles frequencies were compared between AR group and 2 control groups; healthy controls and disease control (none AR cases) . In addition, the AR group had more frequent GT, TT genotypes and T allele than healthy controls .While in G2677T, the frequency of GT, TT genotypes and T allele were significantly higher among AR KTRs than their frequency among None AR KTRs 3435GT 2677 and CT 3435 TT 2677 were significantly higher in AR KTRs than none AR .The effect of combined genotypes is illustrated in Table (p < 0.001). Consequently, the C/D ratio decreased significantly in cases carrying CC then CT then TT genotypes through the 1st 6 months post- transplant (p < 0.001). Similarly, in G2677T, the trough levels were lower among TT than GT than GG genotypes, that reached statistically significant p value in 3rd month and the mean trough level of 1st six months. In addition, the required TAC dose needed to achieve the target trough level was significantly higher among TT than GT than GG genotypes through the 1st 6 months posttransplant (p < 0.001). Consequently, the C/D ratio decreased significantly in cases carrying TT than GT than GG genotypes through the 1st 6 months post- transplant (p < 0.001).The trough levels of TAC, required doses and C/D ratio during the first six months after KT were compared between different genotypes of both SNPs as in Table No significant difference was detected between different MDR1 C3435T and G2677T genotypes as regard frequency of TAC related adverse effects . While in G2677T polymorphism, significantly longer survival was found in GG genotype than TT and GT genotype (p = 0.029).Kaplan-Meier analysis was conducted for time lapse after kidney transplantation in AR group. Cumulative survival proportions as well as median survival time are shown in Fig. To the best of our knowledge, this is the first study that analyses the role of MDR1 gene polymorphism in KT among children in Egypt and Arab countries. It is important to draw up a different treatment plan for each KT recipient. As MDR1 shows great heterogeneity among different ethnic groups, there is a need for pharmacogenomic testing prior to TAC administration to achieve genotype-guided dose and contribute to a better-individualized IS therapy. In the present study, we evaluated the impact of MDR1, C3435T and G2677T on the occurrence of AR and variability in the TAC pharmacokinetics in pediatric KTRs.(p > 0.05 for each).Considering TT genotype as a reference genotype and T allele as a reference allele in C3435T SNP; the current study revealed that the CC, CT genotypes and C allele were significantly associated with risk of AR when compared to none AR and to the healthy controls. This means that the presence of single C allele of C3435T can be a risk factor of AR in KTRs. When comparing none AR versus Control, no significant difference was found regarding C3435T genotypes and alleles with none AR Our results are quite similar to another pediatric study of KTRs that reported higher incidence of AR in CT genotype, without reaching the statistically significant value. It was suggested by the authors that the presence of wild type, C allele increases drug efflux out of cells and decreases drug concentrations in the target cells which eventually leads to AR. It is difficult to explain why this effect was not observed in the homozygous CC genotype. However, it can be attributed to small number of cases (only 38 cases from Saudi Arabia) in their study . Our resIn G2677T, considering GG genotype and G allele as references, both GT, TT genotypes and T allele were found to be significantly higher among AR cases that means that T allele is considered a risk for AR in KTRs. This may be further confirmed by the survival analysis that revealed best survival with GG  genotype.The current findings are similar to another study in Caucasian population with higher incidence of AR in TT and GT than GG genotype . However3435GT 2677 and CT 3435 TT 2677 were significantly higher in AR KTRs than none AR. This finding can be explained by linkage disequilibrium (LD) between both SNPs that may contribute to functional alteration rather than the effect of single haplotype variation [The effect of combined genotypes indicates that both CT ariation .In the present study; assessment of patients′ TAC trough levels and required doses, across 1st 6 months posttransplant, revealed that higher TAC doses and lower C/D ratio were observed among CC than CT than TT genotypes of C3435T, through the 1st 6 months. The current results mean that patients with CC genotypes had difficulty to achieve the trough levels and required higher doses to reach it in comparison to CT and TT genotypes. This effect can be explained by the role of C3435T SNP, in regulating the expression of P-gp expression and controlling efflux of TAC, other drugs and toxic metabolites . It was The current results are similar to the data reported in both kidney and liver transplantation , 41. SimThe current study found that TT genotype of G2677T required higher TAC doses to achieve the target trough level than the GT and GG genotypes, with lower C/D ratio. Our results are contradictory to Mai et al. study. In the latter study; the authors concluded that both C3435T and G2677T SNPs do not affect TAC pharmacokinetics in KT recipients with stable graft function . This diCYP3A5 genotype can affect TAC dose requirements [Tacrolimus is not only a substrate of P-gp, but also it undergoes extensive metabolism by intestinal and hepatic CYP3A4 and CYP 3A5. Thus, TAC intestinal efflux mediated by P-gp is not the only mechanism altering the drug bioavailability. It was actually concluded from another study that irements . In addiirements .As regard the effect of MDR1 SNP genotypes and haplotypes on TAC induced adverse effects, including nephrotoxicity, neurotoxicity, new onset diabetes after transplantation (NODAT), dyslipidemia and hirsutism, no significant association was found between both C3435T and G2677T genotypes and TAC side effects. This is similar to another study that found no significant association between another MDR1 gene SNP (G2677T) and the TAC related nephrotoxicity, neurotoxicity or hypertension . On the The regression analysis of many risk factors for AR as the degree of HLA mismatch, CMV risk and utilized induction and maintenance therapy revealed that no significant difference was found between the AR and none AR groups. This finding supports our argument that MDR 1 genotypes and alleles polymorphism has an impact on occurrence of AR. This can be explained by effect of MDR1 pharmacogenetics on tacrolimus metabolism. Although all of our cohort achieved the trough levels, the risky genotypes (CC genotype of C3435T and TT genotype of G2677T) had relatively lower levels than other genotypes. In addition, they required higher doses and frequent titration of the dose to achieve the trough levels so they were more predisposed to the risk of AR.As regard the similarity between our control cohort and other documented genotypes of both studied SNPs in the different populations, published in the literature, no significant difference was found and no deviation from Hardy-Weinberg equilibrium (HWE) was observed Table . Study fMDR1, C3435T and G2677T SNPs may have a role in tailoring immunosuppressive regimen in pediatric KTRs. CC, CT genotypes and C allele of C3435T and GT, TT genotypes and T allele of G2677T SNP, could carry a risk for AR due to difficulty in achievement of TAC trough level. To date, there is no consensus on routine MDR 1 genotyping prior to solid organ transplantation to guide the choice of appropriate TAC dose. However, analysis should be performed in resourceful settings to guide TAC dose and anticipating potential outcomes as AR or drug toxicity.Below is the link to the electronic supplementary material.Supplementary Material 1


BackgroundAllergic rhinitis (AR) is considered a high global disease burden; hence, the shortage of knowledge would lead to poor adherence to management and preventive measures and increase the exacerbation of AR symptoms. This study aimed to evaluate the prevalence and risk factors, and assess the knowledge and practices of the population regarding AR among the population in Makkah city, Saudi Arabia.MethodologyThis was an online survey cross-sectional study conducted in December 2022 via social media platforms (WhatsApp and Twitter) to collect data on participants’ demographics, prevalence, risk factors, knowledge, and attitudes toward AR, using a validated Arabic version of a self-administered questionnaire.ResultsThe study involved 466 participants. Of the participants, 55.8% were aged 31 to 45 years, and 286 (61.4%) were females. The prevalence of AR among the participants was 45%. The most common symptoms were a blocked nose (79.6%), sneezing (74.2%), and a runny nose (71.5%). Furthermore, the prevalence of rhinoconjunctivitis in this study was 56%. The most common inhalant allergen was house dust (73.0%). Only the age and history of asthma or eczema were significant factors associated with AR. Overall, most of the subjects (94.85%) had adequate knowledge regarding AR.ConclusionA high prevalence of AR was observed. Understanding the factors linked with AR is imperative to ensure better adherence to preventive management plans. Allergic rhinitis (AR) is a non-communicable disorder of nasal hypersensitivity that occurs in response to an allergen that activates the immune system causing inflammation. The cardinal nasal symptoms of AR are rhinorrhea, sneezing, nasal congestion, and itching. They diminish spontaneously or after medical treatment ,2. The mA study reported that the prevalence of AR was 15-25% across Asia, Europe, the Americas, and Africa .One study involving 900 Saudi adults reported an AR prevalence of 34% . In the AR is a global health burden. Despite being a non-severe illness, it is affecting social life, work, and academic performance ,8. The eThe epidemiologic data on AR in the Makkah region of Saudi Arabia is inadequate. Therefore, this study aimed to determine the prevalence of AR among the population of the Makkah region, Saudi Arabia. Moreover, we assessed the knowledge and attitudes regarding AR and identified common allergen triggers and risk factors in this population.A cross-sectional study was conducted in December 2022 by posting an online survey on social media platforms to collect data on participants’ demographics and the prevalence, knowledge, and attitudes toward AR among the residents in the Makkah region, Saudi Arabia, using a validated Arabic version of a self-administered questionnaire .The sample size of this study was determined according to the Raosoft calculator  to be more than 385 participants, considering a confidence interval of 95% and the level of significance  at 5%. Randomly, 466 participants replied to the questionnaire. Individuals who were above 16 years and lived in the Makkah region were included.The questionnaire comprised items to collect participants’ demographic data, previous history of AR, results of allergic test if previously done, the presence of allergenic symptoms in the last 12 months, its triggering factors and the season of its occurrence, the type of medications used for relief of the symptoms of AR, and lastly, the knowledge and attitude toward AR.SPSS statistics version 22  was used to analyze the data. Statistical significance was described as a p-value < 0.05. Categorical variables are represented as frequencies (percentages). The chi-square test was conducted to examine the relationships between different demographic data and the prevalence of AR for bivariate analyses. Concerning knowledge questions (n = 7), a score of “1” was given to correct answers while a score of “0” was given to incorrect answers. The overall score and its percentage were calculated. Individuals who scored less than 50% were considered to have “inadequate knowledge” and those who scored 50% and more were considered to have “adequate knowledge.”The Biomedical Research Ethics Committee of Umm Al-Qura University authorized this study (IRB number: HAPO-02-K-012-2022-11-1329).This survey was performed among the population of the Makkah region of Saudi Arabia. We explored the presence of AR in 466 participants. Table The prevalence of AR among the participants was 45.0%. More than two-thirds of the subjects had sneezing 74.2%), a runny nose (71.5%), and a blocked nose (79.6%) within the past year, excluding a common cold. Itchy, watery eyes occurred in 56.0% of the participants. These symptoms were more frequent in winter (30.0%), followed by summer (29.4%). House dust was the most mentioned trigger factor for these symptoms (73%). Around two-thirds (73.0%) of the participants had a lack of sleep due to the debilitating symptoms. More than two-thirds of the subjects (70.2%) believed AR to be allergic. Nevertheless, just 29.4% of the participants had been investigated for allergies; among them, half were positive for the allergy test. About one-third of the participants (33.3%) stated to have been diagnosed with asthma or eczema. A family history of allergy was declared by the majority of the participants (68.2%)  and the presence of asthma or eczema (p = 0.000) . Most 84.8%) of the subjects had a good knowledge of the definition of AR. The majority (83.5%) realized that nasal sprays could be used for reducing AR symptoms. The majority (82%) agreed that AR was not a contagious disease. On the other hand, half of the participants (51.9%) knew that AR is a genetically inherited disease and is linked to asthma and conjunctivitis (49.6%)  avoided house dust and smoke and 71.2% strictly followed the doctor's instructions Table .AR is a major burden on patients that affects their quality of life in all aspects . This stThe prevalence of AR was reported to be 45.0% among the participants in this survey study. This finding was higher than that of previously published studies. A recent study done in Al Baha city, Saudi Arabia reported a slightly lower prevalence: 32% and 38.6% in males and females, respectively . A studyOur data revealed that most nasal symptoms were more noted in winter in comparison to other seasons, corroborating the findings of previous studies ,14. As dContrary to the previous studies, most of the individuals in the present study had adequate knowledge of AR ,16. In tIn our result, the practice of the participants toward AR was similar to those reported by the previous studies conducted in Saudi Arabia and Canada ,17.This study had several limitations. First, the cross-sectional design confirms only association. Second, the limit to a specific city could influence the generalizability of the results. Third, we explored the prevalence of AR in adults, and this may not represent the actual prevalence in all age groups. Nevertheless, this study presents public health significance in exploring the magnitude, determinants, knowledge, and practice associated with a common disease influencing the quality of life in our society.This study revealed a high prevalence of AR among the residents of Makkah, Saudi Arabia. More consideration should be given to AR in this area. House dust was the most important allergen cause among participants. Appropriate recognition and evaluation of the disease is important and could guarantee early management and improvement of the quality of life.


With the advent of faster magic-angle spinning (MAS) andhigher magnetic fields, the resolution of biomolecular solid-state nuclearmagnetic resonance (NMR) spectra has been continuously increasing. As adirect consequence, the always narrower spectral lines, especially inproton-detected spectroscopy, are also becoming more sensitive to temporalinstabilities of the magnetic field in the sample volume. Field drifts inthe order of tenths of parts per million occur after probe insertion or temperaturechange, during cryogen refill, or are intrinsic to the superconductinghigh-field magnets, particularly in the months after charging.As an alternative to a field–frequency lock based on deuterium solventresonance rarely available for solid-state NMR, we present a strategy tocompensate non-linear field drifts using simultaneous acquisition of afrequency reference (SAFR). It is based on the acquisition of an auxiliary1D spectrum in each scan of the experiment. Typically, a small-flip-anglepulse is added at the beginning of the pulse sequence. Based on thefrequency of the maximum of the solvent signal, the field evolution in timeis reconstructed and used to correct the raw data after acquisition, therebyacting in its principle as a digital lock system. The general applicabilityof our approach is demonstrated on 2D and 3D protein spectra during varioussituations with a non-linear field drift. SAFR with small-flip-angle pulsescauses no significant loss in sensitivity or increase in experimental timein protein spectroscopy. The correction leads to the possibility ofrecording high-quality spectra in a typical biomolecular experiment evenduring non-linear field changes in the order of 0.1 ppm h Maläret al. (2021) describe a spectrometer equipped with a magnet-bore heatersystem that prevents major long-term field drifts due to temperature changesinside the magnet bore, which greatly increases stability and shortens timeconstants to reach a stable field after a disturbance. External locks canmonitor the Another solution that eliminates the effect of the field drift in thespectra is data correction after the acquisition. Referencing to an internalOur work presented here extends the linear drift compensation  for a general non-linear case with no strict assumptions onthe expected progress of the field over time including, e.g., the changesappearing during a helium fill. This is necessary especially for experimentsstarted within several hours after sample insertion or after or during refill ofliquid helium or nitrogen to the magnet, when long-lasting fieldperturbations emerge. We propose to monitor the magnetic field for eachtrace of a multidimensional experiment. On current spectrometers, the fieldmonitoring can proceed as simultaneous acquisition of a frequency reference(SAFR): a reference spectrum with a small-flip-angle pulse is recordedbefore each scan of the experiment. For high-field magnets, the flip anglecan be chosen short enough . A deuterated and 100 % back-exchanged ASC sample (dASC) wasprepared in the same way except that deuterated water, glucose, and ammoniumchloride were used. Exchangeable sites were then re-protonated by solventexchange with HPodospora anserina .Uniformly 3.2The NMR experiments were performed using Bruker triple-resonance MASprobe heads on two wide-bore 850 MHz Bruker Avance III HD (running Topspin 3software) and a standard-bore 1200 MHz Bruker Avance NEO (Topspin 4)spectrometers. 3.3The SAFR block usually consists of a small-flip-angle pulse on protons andthe acquisition of an FID preceding the main experiment . It isrepeated every scan and summed up and stored to disk at the same time as thedata of the main experiment, i.e., before the acquisition of the next rowof a multidimensional experiment is started. No differences in totalexperimental time and longitudinal relaxation to equilibrium are introducedsince the entire SAFR block is placed during the relaxation delay and thesmall-flip-angle pulse does not disturb the equilibrium polarizationnoticeably. There are options in the pulse programs, which switch the SAFRblock off , include decoupling on anadditional channel, or acquire a one-dimensional spectrum by the same pulseprogram. We distinguish homonuclear and heteronuclear SAFR with respect tothe nucleus detected in the main experiment. Homonuclear variants work withone receiver and use separated memory buffers . Incontrast, heteronuclear cases need hardware that allows acquisition onmultiple receivers, which is possible with modern commercial spectrometers(default on Bruker Avance NEO).Representative examples of homonuclear, When multiple receivers allow detection on two channels in one pulsesequence, X-detected experiments can be accompanied with SAFR on 3.4For the calculations described in Sect. 2, we have written an AU program“safrcorr”. The code builds upon the grounds laid for the linear driftcompensation by Najbauer and Andreas (2019) with permission from theauthors. It can be run directly in Topspin (Bruker), but its core is inC4We present here a collection of 4.1Sample cooling is needed to compensate for the temperature rises by frictionduring fast-MAS experiments, and a temperature of the input gas as low as 240 K is needed. Even after reaching an equilibrium within the sample, which canbe monitored by the As an example, we measured a 2D SAFR-hNH spectrum of the per-deuteratedPYRIN-domain of apoptosis-associated speck-like protein , dASC, 91 residues, shortly after cooling of theincoming nitrogen gas from 280 to 240 K had started. The bore-temperaturecontrol system, present and functional on the setup used, was disabledduring this procedure. SAFR with a 0.54.22D hNH CP experiments were acquired on dASC during the helium filling on an850 MHz magnet. SAFR using the water resonance of the sample was used tomonitor the field drift. The 2D experiment was recorded in four identicalblocks of eight scans, and the 2D FIDs were summed up before Fouriertransform. We demonstrate that even when the individual experimental timeswere set relatively short (83 min), non-linearities in the fieldevolution occur . The drift mostly affects the positions of theresonances, but the line shapes are distorted as well, visible mainly inexperiments 2 and 3 in Fig. 5b. Both the positions and the shapes of thepeaks are restored after the correction, such that possible differences to acontrol experiment remain negligible .Moreover, the summed spectra in Fig. 5a and b emphasize the peakbroadening that would be caused by the spectral summation without the driftcorrection and, at the same time, that SAFR does not require chemical-shiftcalibration of individual spectra when the whole progress of the field driftas in Fig. 5c is known.4.3The performance of SAFR was further exploited during a 3D experiment. Figure 6 shows a CP-based 3D SAFR-hCANH spectrum of dASC  in a 1200 MHz magnet during helium fill. The improvementafter the drift correction is obvious. The distortions in the spectrumbefore the correction would make it useless, which is explained by the strongfield drift observed in Fig. 6b. Note that the field drift stayedsignificant for two days; without SAFR, this instrument time could not havebeen used for a reliable 3D. The periodic field oscillations in the inset ofFig. 6b are not caused by the actual experiment but were inherent to themagnet control system at that time and were later improved by themanufacturer. The strongest influence of the drift is seen along the4.4The 2D SAFR-hCH of a complex of two subunits of archaeal RNA polymerase II, Rpo4.5The correction scheme assumes that the solvent (water) chemical shift isconstant. It is however known that it is temperature-dependent and changesby 0.0111 ppm Although we expect that the drift correction is mostly needed forFurthermore, we assume that the perturbations to be corrected are slow andno changes occur within the duration of a single FID. In addition, wecorrected each FID of an experiment  as a wholeentity. At the cost of higher storage demand and additional pre-processingsteps, each scan can be corrected individually in principle, but this didnot turn out to be necessary .5We have presented a new strategy to eliminate line-broadening and spectralartifacts arising from the instabilities of the magnetic field inhigh-resolution solid-state biomolecular spectroscopy. By adding asmall-flip-angle experiment at the beginning of the pulse sequence, weobtain a frequency reference (SAFR) which can be used to correct digitallythe FIDs. An automated procedure facilitating these steps and someexample pulse programs commonly employed in biological solid-state NMR aredeveloped and made available. In its principle and outcome, SAFR isequivalent to a lock system: it detects the position of the solvent (orother intense and preferably narrow) peak and corrects the acquired data forthe corresponding frequency shift. The main difference is that thecorrection using SAFR is performed after, not during the acquisition. Ourwork has demonstrated the importance of a lock in various 2D and 3Dcorrelation experiments under different conditions: an often encounteredchallenge is the insertion of a sample to the probe head and its temperaturechange, which can delay the start of a conventional acquisition by severalhours. SAFR overcomes this problem without the need for a hardware solution,such as a bore-temperature control system. Next, the filling of thecryogenic liquids into the magnet induces non-linear transient fielddisturbances, which last for hours or even days. Again, their effects on theNMR spectra can be corrected by SAFR. Finally, the field strength isaffected by external fields or temperature changes in the room that areunpredictable, but SAFR will be helpful in these cases as well.SAFR requires a well-resolved and intense resonance line in the spectrum.The In our experience, highly resolved 10.5194/mr-3-15-2022-supplementThe supplement related to this article is available online at: https://doi.org/10.5194/mr-3-15-2022-supplement.