Npr1 knockout (+/−Npr1) mice and found that differentially expressed genes were significantly related to cell adhesion. This result was supported by an increased expression of intercellular adhesion molecule 1 (ICAM-1) in the aortic endothelium of +/−Npr1 mice. Moreover, we observed that the knockdown of NPR1 increased ICAM-1 expression and promoted THP-1 monocyte adhesion to human umbilical vein endothelial cells (HUVECs). NPR1 overexpression decreased ICAM-1 expression and inhibited the adhesion of monocytes to HUVECs treated by TNF-α (a cell adhesion inducer). Further analysis showed that adhesion-related genes were enriched in the focal adhesion signaling pathway, in which integrin beta 4 (Itgb4) was determined as a key gene. Notably, ITGB4 expression increased in vascular endothelium of +/−Npr1 mice and in NPR1-knockdown HUVECs. The deficiency of ITGB4 decreased ICAM-1 expression and attenuated monocyte adhesion to NPR1-knockdown endothelial cells. Additionally, a reduced NPR1 and an increased ITGB4 expression level were found in an atherosclerosis mouse model. In conclusion, our findings demonstrate that NPR1 deficiency increases vascular endothelial cell adhesion by stimulating ITGB4 expression, which may contribute to the development of atherosclerosis.Natriuretic peptide receptor 1 (NPR1) serves as a modulator of vascular endothelial homeostasis. Interactions between monocytes and endothelial cells may initiate endothelium dysfunction, which is known as an early hallmark of atherosclerosis. In this study, we performed RNA-sequencing analysis for the aorta of  ITGB4) [ICAM-1) [NPR1) [Npr1-deficient mice on an apolipoprotein E (Apoe) knockout background exhibit more severe atherosclerotic lesion compared with mice with Apoe-knockout only [Vascular endothelium is a single layer of endothelial cell lining of blood vessels, which plays a critical role in maintaining vascular homeostasis ,2. ImpaiITGB4) , interce[ICAM-1) , and nat) [NPR1) . ITGB4 i) [NPR1) ,13. ITGB) [NPR1) . An elev) [NPR1) . Likewis) [NPR1) . ICAM-1 ) [NPR1) . ICAM-1 ) [NPR1) . Increas) [NPR1) ,18,19. M) [NPR1) . NPR1 is) [NPR1) ,22. A la) [NPR1) . Importa) [NPR1) . A study) [NPR1) . Npr1-deout only . To dateNpr1 knockout (+/−Npr1) mice to search for novel genes associated with vascular aging. Interestingly, we found that the differentially expressed genes (DEGs) were significantly enriched in the signal pathway related to cell adhesion. Therefore, in this study, we investigated the effect of NPR1 on cell adhesion at the cellular level and in the different mouse models. We demonstrate that NPR1 participates in modulating monocyte–endothelial cell adhesion.Very recently, we reported that NPR1 is essential to regulate endothelial cell senescence and vascular aging . SubsequNpr1+/− mice, a decreased NPR1 expression in the aorta, especially in the endothelium, was confirmed by immunofluorescent staining (Npr1+/− and wild type (WT) mice. A total of 2184 DEGs  was found . Western blot analysis showed a reduction in NPR1 protein levels in HUVECs transfected with two sets of siRNAs (siNPR1-1 and siNPR1-2), compared with the non-targeting control siRNA  analysis on cell-adhesion-related genes. We found that these genes were enriched in pathways linked to focal adhesion, ECM–receptor interaction, cell adhesion molecules, PI3K-Akt signaling pathway, and cardiomyopathy. Among them, focal adhesion was the one with most significant change A, in whi network C. Throug WT mice D. Througn HUVECs E. FurtheNPR1 and ITGB4 in HUVECs. HUVECs were co-transfected with siNPR1 and siITGB4 and then incubated for 48 h. Western analysis showed that the expression levels of NPR1 and ITGB4 were significantly diminished, indicating a high knockdown efficiency . Human monocytic cell line (THP-1)  was cultured in RPMI-1640 medium  with 10% fetal bovine serum . All cells were kept in an incubator containing 5% CO+/−Npr1 mice were established as previously described  [Apoe knockout (−/−Apoe) mice (8 weeks)  on a high-fat diet for 9 weeks. Wild-type (WT) mice were fed with a high-fat diet as controls. This research recruited male mice only. , China) . Genotypg for 5 min at 4 °C. The supernatant was collected and mixed with chloroform. After centrifugation, RNA in the aqueous phase was precipitated by mixing with isopropanol at −20 °C for 1 h. Then, the RNA pellet was washed twice and resuspended. The sample was centrifuged at 13,000× g for 5 min at 4 °C. The dried pellet was dissolved by DEPC-treated water. The quality and quantity of total RNA were assessed using Nano Drop  and Agilent 2100 Bioanalyzer .Cultured cells or mouse tissues were incubated with Trizol reagent  and centrifuged at 13,000× −ΔΔCt method. Total RNA was reverse transcribed into cDNA using a reverse transcriptase kit . qPCR was conducted with M5 HiPer Realtime PCR Super mix  using qTOWER3 G Real Time PCR Systems . The primer sequences used in the study are listed below. Mus-Npr1: forward-5′-AGA CGA TGG GCA GGA TAG G-3′, reverse-5′-GGA AGG ATG CTG GGA TGA T-3′; Mus-Itgb4: forward-5′-GTC GCC GTC TGG TAA ACA T-3′, reverse-5′-ACC TGG TCT CCA CGA CTC AC-3′; Mus-Actin: forward-5′-AGA GGG AAA TCG TGC GTG AC-3′, reverse-5′-CAA GAA GGA AGG CTG GAA AA-3′. The Ct values were obtained according to the amplification curve. The relative expression of Npr1 and Itgb4 was calculated by the 2www.webgestalt.org, accessed on 28 October 2021). The sequencing data were filtered to produce clean reads using SOAPnuke software. The clean reads were mapped and aligned to the reference coding gene set with Bowtie2 (v2.25). The expression level of genes was evaluated by RSEM (V1.2.12). Differential expression analysis was executed by DESeq2 (v1.4.5) with q value ≤ 0.05. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses were carried out by over-representation analysis (ORA) in the WEB-based GEne SeT AnaLysis Toolkit (5) were seeded in six-well plate and cultured overnight. After replacing with Opti-MEM , the cells were transfected with siRNA targeting NPR1 gene using Lipofectamine 2000  for 48 h. A non-targeting siRNA was used as a control. The sequences of siRNA were designed and synthesized as follows. Control siRNA: 5′-UUC UCC GAA CGU GUC ACG UTT-3′, siNPR1-1: 5′-GCA AAG GCC GAG UUA UCU A-3′, siNPR1-2: 5′-CCU AUG AGC AGU UCA ACU U-3′, siITGB4-1: 5′-CCA GGA AGA UCC AUU UCA ATT-3′, siITGB4-2: 5′-GCA CGU GUG AGG AAU GCA ATT-3′. HUVECs (1.2 × 10NPR1 (ADV-NPR1)  for 48 h. Then, the cells were treated with TNF-α at a final concentration of 5 ng/mL  for 24 h and used for additional experiments. HUVECs were transfected with adenovirus expressing human Frozen sections were fixed with 4% neutral buffered paraformaldehyde  for 10 min and then blocked with PBST containing 1% BSA for 2 h at room temperature. After blocking, the sections were incubated with primary antibody including NPR1 , ITGB4 , ICAM-1 , and CD31  at 4 °C overnight. Subsequently, the sections were incubated with secondary antibody Cy3-labeled donkey anti-rabbit IgG  or Cy5-affinipure donkey anti-goat IgG  at room temperature 1 h. The nucleus was stained with Hochest3342 . The sections were examined by confocal microscope .Protein from cells was extracted with RIPA buffer . The sample was loaded onto 12% SDS-PAGE gel for electrophoresis and then transferred onto a PVDF membrane. After blocking by 5% skim milk at room temperature for 2 h, the membrane was incubated with primary antibody targeting NPR1 , ITGB4 , ICAM-1 , and GAPDH  at 4 °C overnight. Afterwards, incubation of secondary antibody HRP goat anti-rabbit IgG  or HRP goat anti-mouse IgG  was carried out at room temperature for 2 h. The protein band was detected by Tanon 5200 Chemiluminscent and Fluorescent Imaging System . 2 at 37 °C. Then, monocytes were seeded onto HUVECs at a density of 5.0 × 106 cells/mL per well in a 24-well plate. After incubation at 37 °C for 1 h, the non-adherent cells were rinsed off by PBS. The monocyte adhesion to HUVECs was detected by fluorescence microscope . Monocytes (THP-1) were incubated with 10 μmol/L BCECF-AM  for 1 h in an incubator with 5% COThe mouse aorta frozen section was fixed with 4% neutral buffered paraformaldehyde  for 10 min and then rinsed with 60% isopropanol. The section was stained with Oil Red O solution  for 15 min. The nucleus was stained with Gill’s hematoxylin  for 30 sec. After rinsing with distilled water, the section was mounted in glycerine jelly .® Assay Kit . HUVECs were lysed with 100 µL of lysis buffer. The samples (50 µL) were incubated with 50 µL of cGMP-HRP conjugate for 3 h at room temperature. TMB substrate was then added to the samples for 30 min incubation. After adding the stop solution, the optical density values were determined at 450 nm using SpectraMax i3x .cGMP concentrations were measured using the Cyclic GMP XPt-test was used for two groups. A p value < 0.05 indicates statistical significance.All data are presented as the mean ± SD. Statistical analysis was carried out using GraphPad PRISM version 8.4.2 . One-way ANOVA with Dunnett’s multiple comparison was used for three groups and two-tailed Student’s


The influence of the current density, and the power source in the EDBM stage have been evaluated on a laboratory scale while the influence of the feed stream concentration in the evaporation stage has been obtained through simulations using Aspen Plus. The lowest SEC of the integrated process (SECOV), 31.1 kWh·kg−1 NaOH, is obtained when an average current density of 500 A·m−2, provided by a power supply (grid mix), is applied in the EDBM stage. The environmental burdens of the integrated process have been quantified by achieving reductions in the CF by up to 54.7% when solar photovoltaic energy is employed as the power source for EDBMs, with a value of 5.38 kg CO2-eq.·kg−1 NaOH. This study presents a great potential for the introduction of the principles of a circular economy in the water industry through the recovery of NaOH from the high salinity waste stream generated in SWRO facilities and opens the possibility of the reuse of NaOH by its self-supply in the desalination plant.Electrodialysis with bipolar membranes (EDBMs) is a technology that offers a great potential for the introduction of the principles of a circular economy in the desalination industry, by providing a strategy for the recovery of HCl and NaOH from brine via the process of seawater reverse osmosis (SWRO). Both chemicals are widely employed in desalination facilities, however NaOH presents a special interest due to its higher requirements and cost. Nevertheless, the standard commercial concentrations that are commonly employed in the facilities cannot be obtained using the state of the art EDBM technology itself. Therefore, the aim and main purpose of this work is to prove the technical and environmental feasibilities of a new approach to produce commercial NaOH (50%wt.) from SWRO brine by means of an integrated process of EDBMs followed by a triple effect evaporation. The global process has been technically evaluated in terms of the specific energy consumption (SEC) (kWh·kg However, remarkable research efforts have been carried out in the last few years regarding the development of integrated systems which combine different technologies, the so called minimum liquid discharge (MLD) and zero liquid discharge (ZLD) systems, with the aim of avoiding or at least minimizing the volume of liquid waste streams that are generated and discharged into the environment ,23,24,25−3 of freshwater and of NaOH of 30–60 g·m−3 of freshwater, both employed at commercial standard concentrations, 31–35%wt. and 50%wt., respectively [−1 for the HCl 35%wt. and 196.43 EUR·ton−1 for the NaOH 50%wt. [Both HCl and NaOH are highly consumed in SWRO facilities, e.g., a SWRO plant located in the Mediterranean area requires doses of HCl of 0.2–0.5 g·mectively . ConcentH 50%wt. .The literature shows the increasing relevance of the recovery of NaOH and HCl by different technologies such as electrodialysis, EDBMs, or electrosynthesis ,29.−1 for both HCl and NaOH [−1 (~10.2%) of HCl and 3.6 mol·L−1 (~9.7%) of NaOH can be obtained by means of EDBMs from brine using this technology in its current state [The EDBM technology is able to produce HCl and NaOH from brine and electric energy. The literature commonly reports concentrations lower than 2.0 mol·Land NaOH ,34,35,36nt state . Similarnt state ,37 instent state ,39. Thes2O was simulated using the Aspen Plus [−1 to 3.0 mol·L−1), i.e., the output of the EDBM, in the specific energy consumption (SEC), from both the distillation and the integrated EDBM + distillation processes were evaluated. Different scenarios were considered for the EDBM process , which differed in the average current density and the power supply source selected, and both variables conditioned the EDBM output product concentrations.Previous studies by the research group were focused on the analysis through the simulation of the HCl concentration stage, using as feed, a diluted form of HCl, experimentally obtained in an EDBM process from SWRO brine and powered by a grid mix (constant current density) and PV solar energy (variable current density) . An azeopen Plus  softwareDespite the fact that the production of the commercial standard concentration of HCl has been evaluated, there is a need to provide strategies to obtain commercial or at least highly concentrated solutions of NaOH from highly salty waste streams. Moreover, the NaOH recovery presents a great interest due to its higher consumption in SWRO facilities and higher market prices, compared with HCl.EV) and the integrated EDBMs and evaporation process (SECOV), and the environmental performance by means of the carbon footprint (CF).Thus, the aim of the present study is to contribute to the development of new strategies that integrate the membrane processes with the complementary stages based in sustainability principles, by presenting for the first time in the literature, the performance of an integrated process including EDBMs and evaporation stages fed by SWRO concentrates, in order to achieve the commercial concentrations of NaOH (50%wt). The evaluation is carried out through an analysis of the energetic performance by means of the SEC of the evaporation  and two cation membranes to create the electrolyte compartment. The commercial membranes AM-PP RALEX as anion and CM-PP RALEX as cation from Mega (Czech Republic), and Fumasep FBM from Fumatech (Germany) were selected.The experiments were performed in a modified PCCell (Germany) bench scale laboratory ED system, using a cell composed of two electrodes made of titanium and coated with ruthenium oxide and an effective area of 100 cm−1 NaCl), 1 L of 0.1 mol·L−1 HCl, and 1 L of 0.1 mol·L−1 NaOH were employed as initial solutions.A 20 L quantity of a simplified synthetic model SWRO brine  supported by the grid mix, and the variable current density, using a PV solar array simulator  that emulated the use of the PV panels, was analyzed considering three average current densities 500 A·m−2, 750 A·m−2, and 1000 A·m−2. However, the case of the variable current density is more complex.When the constant current densities are employed, these will take the value of the average current density 500 A·mThe PV solar array simulator emulates the performance of a PV panel by introducing an irradiation profile and the panel parameters. In this study, the same conditions as those used for the previous studies are employed ,37. An aA more detailed description of both the experimental set-up and procedure was explained in the previous studies .In order to obtain NaOH at commercial standard concentrations (50%wt.), the simulation of the NaOH concentration stage, by means of evaporation after a first stage of the EDBM, was carried out.Aspen Plus  was usedAs depicted on The heat exchange in an evaporator can be produced isothermally (constant temperature) or isobarically (constant pressure), in this simulation, the constant pressure has been selected, with pressures of 1.00 atm, 0.75 atm, and 0.50 atm for the first, second, and third effects, respectively.The feed stream is introduced in the third effect, using the liquid output of this effect as feed for the previous effect and so on, successively until the final product (NaOH 50%wt.) is obtained as the liquid output of the first effect.Moreover, the first effect heat transfer is carried out by a saturated industrial steam stream at 200 °C. The second and third effects are fed with the vapor streams produced in the previous first and second effects, respectively. The diluted NaOH from the EDBMs is considered to be fed at 20 °C, a temperature that could fit in the EDBM outlet without heating or refrigeration between the EDBMs and the evaporation processes.In this way, the system has two inputs, feed (NaOH from EDBM) and steam, while it has five outputs, the targeted product (NaOH 50%wt.), the steam from the third effect, and the condensates (considered as 100% water) from the three effects. Thus, in addition to the targeted product, water that can be reused and steam that can be recompressed for later use, are obtained.−1), which includes the concentrations of NaOH obtained by means of the EDBMs in previous experimental studies [Focusing on the simulation, the required input data is the concentration of the NaOH from EDBM stream, considering a range of 7–10%wt. (2.6–3.8 mol·L studies . The proEDBM) is calculated on the basis of the NaOH (target product) produced, through Equation (1):S is the enthalpy of the steam stream, and xF is the mass fraction of NaOH in the feed stream. where U is the total stack voltage (V), I is the current intensity (A), CNaOH,te and CNaOH,0 are the concentrations of NaOH at the end and at the beginning of the experiment (mol·L−1), VNaOH is the volume of NaOH (L), PMNaOH is the molecular weight of NaOH (g·mol−1), te is the total time of the experiment (h), and t is time (h).The SEC of the EDBM unit  is calculated from the concentration of the NaOH from the EDBM stream (input to evaporation) and from the requirements of the industrial steam by applying the expression in Equation (2):S is the enthalpy of the steam stream, and xF is the mass fraction of NaOH in the feed stream.Moreover, the SEC of the evaporation (SECOV), that can be calculated as the sum of the SEC of the EDBM process (SECEDBM) and the SECEV (Equation (3)):The evaluation of the integrated process EDBM + Evaporation would be carried out through the calculation of the SEC of the overall process  [The environmental performance of the integrated process of the EDBMs coupled with the evaporation could be assessed through the calculation of the carbon footprint (CF) of the overall energy input to the system. In this sense, the CF is calculated according to Equation (4):energies ) is consselected , and CFS.·kWh−1) .EV, SECOV, and CFOV calculations, are presented.The results from the simulation of the triple effect evaporation carried out using the Aspen Plus software, together with the SEC−1 NaCl), with concentrations up to 3.3 mol·L−1 (~10.2%) of HCl and 3.6 mol·L−1 (~9.7%) [−2, and under different power sources, a grid mix (constant current density) and solar PV energy (variable current density).The experimental study reports the production of HCl and NaOH by means of EDBMs from brine (1.0 mol·L (~9.7%) . Table 1EDBM is also increased. Moreover, similar NaOH concentrations and slightly a higher SECEDBM are obtained when solar PV energy is selected as the power source instead of the grid mix.As seen in Thus, the integration of EDBMs with evaporation with the target of producing NaOH at commercial concentrations (50%wt.) is evaluated in terms of the SEC. In this sense, the feed NaOH concentrations to the evaporation in the range of 7–10%wt. are studied, which correspond with the maximum concentration experimentally achieved under different conditions.−1). As expected, an increase in the feed concentration favors the evaporation process in two ways: (i) industrial steam requirements are reduced, and (ii) the production of NaOH 50%wt. is increased. The production of NaOH 50%wt. is increased in the same proportion as the feed concentration is increased, whereas the industrial steam requirements are not proportional.Increasing by ~43% the NaOH feed concentration (from 7 to 10%) implies a reduction of 3.5% of the requirements of the industrial steam. Likewise, the water recovery will be reduced if the feed concentration is increased, as less water (in terms of proportion) would be fed to the evaporation system.EDBM has been updated from previous experimental results [EDBM between the two products has not been considered, as they are attributed completely to the NaOH as it is the target product due to its higher requirements in the SWRO facility and cost.The SEC results , consideEDBM values for different NaOH concentrations achieved in the EDBM process (EDBM output), thus, a comparison of the profiles of the different current densities can be carried out without depending on the maximum concentration achieved for the product. In addition, the SECEV values for the different NaOH input concentrations to the evaporation system are also included in EDBM values are required. Moreover, the SECEDBM increases if higher average current densities are employed, with increments in the range of 0.79–2.31 kWh·kg−1 of NaOH (dry base) for every 1.0%wt. of the NaOH increase in the concentration at the output stream of the EDBMs.EDBM for the same product concentration  when operated with higher average current densities, even if the operation times can be reduce. However, increasing the average current density is required in order to obtain more concentrated products.Additionally, as higher concentrations than those commonly found in the literature are reported, the influence of non-ideal phenomena such as concentration polarization, proton leakage, or counter diffusion points out, which leads to a higher SECEV is not only influenced by the steam requirements, but also by the production. Therefore, both factors will simultaneously favor its reduction. As disclosed in EV in a 32.4%, nevertheless, this reduction is not linear, as it shows 13.5% for the range of 7–8%, 10.5% for 8–9%, and 8.4% for 9–10%, which means that as the input is concentrated, the impact of the reduction of the SECEV is smaller because the requirements for steam remain high.As seen in equation 2, the SECOV for the integrated process of EDBMs and evaporation in order to obtain NaOH at commercial concentrations (50%wt.), unachievable with EDBMs alone. The higher average current densities report a higher SECOV, nevertheless, given the same SECOV, operating at higher average current densities allows for reaching higher concentrations. moreover, increasing the input concentration, within the same operating conditions, allows the reduction of the SECOV in a range of 6.2–13.8%, due to a rise in the contribution of the EDBM in the SECOV from a 34–47% at 7%wt. NaOH to a 45–59% at 10%wt. NaOH. Under the experimental conditions used, the lowest SECOV is achieved in the scenario G500, −2 and using the grid mix (constant current density) as an electrical power source, especially if the EDBM achieves the maximum NaOH concentrations under these conditions (~7.8%wt. NaOH).OV similar or slightly higher than using grid mix, it can present a better environmental performance. Renewable energies, in particular solar PV energy, present a lower CF than the grid mix, that is commonly based on fossil fuels. As an example, the CF of the current Spanish grid mix can be estimated to 0.338 kg CO2-eq.·kWh−1, whereas the CF of solar PV energy is 0.036 kg CO2-eq.·kWh−1, which is an order of magnitude lower [2-eq.·kWh−1 [Even though, by using solar PV energy as an electrical power source requires a SECde lower . Otherwiq.·kWh−1 .OV provides values between 5.38 kg CO2-eq.·kg−1 NaOH (9.5%wt. and PV1000 + Evaporation) and 13.27 kg CO2-eq.·kg−1 NaOH (7.0%wt. and G1000 + Evaporation). As with the SECOV, increasing the evaporation inlet concentration decreases the CFOV by up to 24.5%. Increasing the average current density increases the CFOV when operating with the grid mix (constant current density), while operating with solar PV energy, the CFOV are very similar, only slightly lower at the higher average current densities. Moreover, replacing the grid mix with solar PV energy allows reductions of up to 38.3%, 41.0%, and 54.7% for the average current densities of 500, 750, and 1000 A.·m−2, respectively.As plotted on OV of 5.38 kg CO2-eq.·kg−1. However, benchmarking against the production of NaOH as reported in the Ecoinvent [2-eq.·kg−1 NaOH) does give lower values than using solar PV energy and steam. If it is assumed that the steam used in the distillation stage is produced by the PV solar energy, the CFOV would be reduced to 1.33 kg CO2-eq.·kg−1 NaOH.Therefore, from an environmental point of view, the best performance is obtained from the scenario PV1000 + Evaporation (9.5%wt.) with a CFcoinvent  databaseHowever, it must be considered that the comparison does not consider the allocation procedure in the EDBM unit in which HCl is also generated as a coproduct, while the value given by the Ecoinvent database does not include transportation from the NaOH production site to the desalination facility. Taking both factors into account could bring the values of our proposal closer to the conventional one.The viability of the production of NaOH at standard commercial concentrations (50%wt.) from SWRO brine by an integrated process that combines the EDBM technology and evaporation has been demonstrated and evaluated in terms of the SEC and CF. The proposed integrated process encourages the valorization of salty waste streams from the water industry and offers a potential strategy for the application of circular economy principles in the desalination industry.EDBM values in the range of 11.2 and 21.5 kWh·kg−1 of NaOH are obtained under the different conditions studied. Despite the fact that selecting higher average current densities lead to higher concentrations and a reduction of freshwater consumption, it also leads to a higher SECEDBM. The SECEV can be reduced by up to 32.4% when the NaOH solutions with higher concentrations (~10%wt.) are fed to the evaporation.The technical and environmental feasibilities has been evaluated from the experimental (EDBM) and the simulation (evaporation) results. The SECOV values between 31.1 and 42.1 kWh·kg−1 of NaOH. The SECOV is reduced when low average current densities are employed in the EDBM stage, although the achieved NaOH concentrations are lower (~7%wt.).The global process generates SECOV, however, it provides a better environmental performance. The minimum value of CFOV of 5.38 kg CO2-eq.·kg−1 NaOH is achieved under solar PV energy and 1000 A·m−2, which means a reduction of up to 54.7%. Even though this value is improved when a renewable power source is employed in the EDBMs, it is still far from the value reported by the Ecoinvent database for the conventional production process of NaOH (1.32 kg CO2-eq.·kg−1 NaOH), which does not consider the transportation of the product from the production site to the desalination facility.Selecting solar PV energy instead of the grid mix as a power source for the EDBMs slightly increases the SECThis work contributes to the introduction of circular economy principles in the water industry through the recovery of NaOH from the high salinity waste stream generated in SWRO facilities and opens up the possibility of the reuse of NaOH through self-supply in the desalination plant.


Thank you so much for your kind remarks. We really appreciate your detailed analysis  of this Firstly, it is very important to understand that, with the increasing rate of stroke-related disability, it will be difficult to provide stroke survivors with post-stroke care (PSC) services because of their unbearable economic consequences, which raises the need to minimize the role of physical therapists and move towards adopting self-rehabilitative home-based therapies to facilitate healthcare for those living in remote areas.Secondly, the rehabilitation field is shifting from conventional approaches to new and technologically advanced therapeutic strategies in which virtual reality, telerehabilitation, robotics, and invasive and non-invasive stimulations are top of the list.For the use of artificial intelligence to fabricate modern medical equipment such as prosthetic limbs, robotic machinery is inevitable. Such systems are strongly bound with the commitment to making rehabilitation systems more comfortable, with a significantly increased degree of freedom for stroke patients or victims of limb amputations.https://www.saebo.com/virtual-reality/) (accessed on 28 March 2022) which is an interactive, multisensory computer-based simulation environment providing the patients with an opportunity to perform different activities in the real world. Saebo also provides a cutting-edge Saeb Glove (https://uk.saebo.com/shop/saeboglove/) (accessed on 28 March 2022) which helps its users suffering from different orthopedic and neurological injuries to incorporate with their motor therapy for assistance at home. This proprietary tension system assists patients to perform finger extension following a grasp action. This fully functional, commercially available setup is a bewildering example of AI-based robot-assisted system for patients with motor disabilities.As An example, I will mention a commercially available system of Saebo-VR (https://www.physio-pedia.com/The_emerging_role_of_Microsoft_Kinect_in_physiotherapy_rehabilitation_for_stroke_patients) (accessed on 28 March 2022) offers exciting and innovative ways of rehabilitation that make the treatment, and thus the subsequent adherence and motivation, more interactive and enjoyable. Microsoft Kinect allows stroke survivors suffering from motor disabilities to interact with an environment where they can perform different movement combinations without any need for a controller or attached device.Moreover, systems such as Microsoft Kinect play significant roles in physiotherapy and rehabilitation of stroke patients. Microsoft Kinect device (This review article provides an overview of, and deep insights into, modern alternative rehabilitation technologies. Moreover, the review article focuses on the importance of stroke rehabilitation while narratively explaining the socio-economic burden of this disease and related risk factors. Considering the increasing popularity and evidence of the benefits of technology-aided rehabilitation approaches, some commonly used stroke therapies to regain muscle activity are discussed. The reader can refer to the cited articles for more information.Despite all presented discussions, we cannot deny the fact that the future is strongly associated with excess use of artificial intelligence in the field of rehabilitation—whether it is telerehabilitation, virtual reality, robot-assisted therapies, or participatory involvement of multiple techniques. Hopefully, I have answered the question. For more details, please refer to the cited article ,3,4,5.


Oryza sativa) during growth. Ideal Plant Architecture (IPA1), the first cloned gene controlling the ideal plant type in rice, has been reported to function in both ideal rice plant architecture and biotic resistance. Here, we report that the IPA1/OsSPL14, encoding a transcriptional factor, positively regulates drought tolerance in rice. The IPA1 is constitutively expressed and regulated by H2O2, abscisic acid, NaCl and polyethylene glycol 6000 treatments in rice. Furthermore, the IPA1-knockout plants showed much greater accumulation of H2O2 as measured by 3,3′-diaminobenzidine staining in leaves compared with WT plants. Yeast one-hybrid, dual-luciferase and electrophoretic mobility shift assays indicated that the IPA1 directly activates the promoter of SNAC1. Expression of SNAC1 is significantly down-regulated in IPA1 knockout plants. Further investigation indicated that the IPA1 plays a positive role in drought-stress tolerance by inducing reactive oxygen species scavenging in rice. Together, these findings indicated that the IPA1 played important roles in drought tolerance by regulating SNAC1, thus activating the antioxidant system in rice.Drought is a major abiotic stress to rice (The online version contains supplementary material available at 10.1186/s12870-023-04062-9. Arabidopsis, 11 of the 17 SPL genes are targets of the microRNA (miRNA) miR156 [Drought is one of the most important factors affecting crop production and has severe effects on food security . Breedin) miR156 , 6.Previous research of miR156 shows that it is an important regulatory element in a variety of plant biological processes, including plant growth, development, environmental stress response and defense . MiR156 SPL genes have been studied primarily for their functions in growth and development. In rice, overexpression of OsSPL16 promotes cell division and seed filling [IPA1 gene, thus decreasing tiller number, and resulting in taller plants and more panicle branches [IPA1 has been identified to play a role in abiotic stresses in rice [IPA1 increases disease resistance to bacterial blight in rice [IPA1 increases drought tolerance in rice seedlings through the abscisic acid (ABA) pathway [IPA1 plays a role not only in regulating plant structure but also in plant resistance to abiotic stresses and diseases.The  filling . Overexp filling . OsSPL14branches . Full ge in rice , 18. Pho in rice . Overexp pathway . In concSNAC3 regulates ROS homeostasis by regulating the expression of ROS scavenging genes, thereby increasing drought tolerance in rice [OSLG3 improves drought tolerance in rice by enhancing ROS scavenging enzyme activity and significantly reducing ROS accumulation [IPA1 knockout transgenic rice and analyzed its function related to drought stress in rice. Research on IPA1 currently focuses on rice plant structure and biotic stresses, whereas studies of abiotic stresses are relatively scarce in rice. Here, IPA1 is demonstrated to positively regulate drought tolerance by affecting reactive oxygen species (ROS) content in rice. Previously, we found that IPA1 regulates many drought-related transcription factors [IPA1 directly regulates SNAC1 and might regulate drought resistance in rice，and suggest a new role for IPA1 in the involvement of drought stress in rice.Under stressful conditions, the balance between intracellular ROS production and clearance is disrupted , 21. Thu in rice . Overexpmulation . Therefomulation . Therefo factors , 19, andOryza sativa L.) from Rice Research Institute, Fujian Academy of Agricultural Sciences, China was used in this study. The germinated seeds were planted in soil, and the seedlings were grown under standard greenhouse conditions (16-h light at 28 °C/8-h dark at 26 °C).The rice varieties FH7185 and MH86  was performed according to (References) [O. sativa L. indica cultivar‘MH86’) embryos with Agrobacterium-mediated transformation. Stably inherited transgenic plants possessing single copy insertions of the transgene were selected and used in this study.The full-length cDNA of erences) . The plaSelecting seedlings at the three-leaf stage for treatment. Polyethylene glycol (PEG) 6000 concentration of 20%, ABA and GA at a concentration of 100 μM, NaCl at a concentration of 100 mM. PEG treatment times of 0 h, 1 h, 2 h, 4 h, 8 h, 12 h, 24 h and 36 h. ABA, GA and NaCl treatment times of 0 h, 1 h, 3 h, 6 h, 12 h, 24 h and 36 h. Sampling by time point, each group with clear water as blank control, three biological replicates per group, three plants per replicate.T4 generation rice plants were used in the experiment. The drought stress experiment was conducted in plastic buckets with soil. For assays of drought treatment, 12 plants of each line were used in each replicate, with three replicates for each line. The plants grew in buckets until the five-leaf stage, after which irrigation stopped for 14 days. After recovery with water for 7 days, the survival rate was measured. Drought stress was simulated in a plastic bucket with 0.5 m soil depth.In dehydration treatment, In the dehydration treatment, WT (MH86) and IPA1-OE plants of uniform growth were transplanted onto 96-well PCR plates and hydroponically grown with nutrient solution. The plants grew until the five-leaf stage, after which polyethylene glycol (PEG) 6000 concentration of 25% treatment for 10 days.Rice leaf RNA was extracted from transgenic rice plants and wild-type FH7185 rice plants. Total RNA was extracted with a TriZol Up kit  according to the manufacturer’s protocol. An RNA reverse-transcription kit with gDNA Remover  was used to generate cDNA for 10 min at 25 °C, 120 min at 37 °C and 5 min at 85 °C. qRT-PCR was performed with ChamQ Universal SYBR qPCR Master Mix  on an ABI Prism 7500 real-time PCR system.IPA1 was amplified and cloned into the PJG4–5 prey vector. The promoters of SNAC1 were amplified and cloned into pLaczi-2u bait vectors. The prey vectors were co-transformed with bait vector into EYG48 strain. The transformed yeast cells were grown on SD/−Trp/−Ura medium and then applied to yeast plates containing 5-bromo-4-chloro-3-indolyl β-D-galactoside. Interactions were screened on the basis of presence of blue pigment. The empty vector pJG4–5 and recombinant pLacZi vectors were co-transformed as negative controls.The coding region of IPA1 coding sequence was fused into the pMAL-C5X vector, and the fusion protein was expressed in Escherichia coli and purified. The double-stranded Cy5.5-labeled probes used in this assay were synthesized by Biosun (China). The EMSA was performed with an EMSA/Gel-Shift Kit  according to the manufacturer’s instructions. Briefly, 2 mg of purified MBP or MBP-IPA1 protein was added to the binding reaction and incubated for 20 min at 25 °C in a thermal cycler . The mixture was separated on a 4% polyacrylamide gel in 0.5× Tris-Borate-EDTA buffer, and the gel images were taken with an Odyssey R Infrared Imaging System .The full length SNAC1 was inserted into the LUC reporter vector pGreen II 0800, which includes a Renilla LUC (REN) gene driven by CaMV35S as an internal control. Then the pRTVcIPA1-HA vector was used as an effector. The reporter and effector plasmids were co-transformed into the protoplasts through the method described above. The transformed protoplasts were incubated in the dark for 36 h at 28 ° C. LUC and REN activity was measured according to the instructions of the Dual Luciferase Reporter Assay Kit . The min35s promoter was used as a negative control. The binding of IPA1 to the candidate gene promoters was expressed as the LUC/REN ratio. All experiments were repeated in three biological replicates.We used a dual LUC reporter assay system to analyze transcriptional activity in rice protoplasts. First, the promoter of 2O2) was stained using DAB, malondialdehyde (MDA), catalase (CAT) and peroxidase (POD) activity were measured according to the manufacturer’s protocol . Rice leaves were taken at 10 days of drought treatment to measure CAT and POD activity, and at 14 days of drought treatment to measure MDA content.The hydrogen peroxide . RNA was extracted from different tissues, and RT-qPCR was performed to determine the expression pattern of IPA1 contributes to the responses to abiotic stress and hormone treatment. The IPA1 transcript levels increased significantly after polyethylene glycol (PEG) 6000 and NaCl treatments   Fig. b. After nes Fig. c. After red Fig. d, indicaIPA1 regulates drought tolerance, we selected transcription factors associated with drought resistance and other drought-associated genes from these three transcription factor families and analyzed the relative expression of these genes by RT-qPCR  and WRKY transcription factors are relatively well described families of transcription factors associated with resistance to abiotic stresses in plants –31. To iIPA1 regulates its target genes by binding directly to the core motif GTAC or indirectly to the core motif TGGGCC/T of target gene promoters [IPA1 [SNAC1 is a potential target of IPA1, suggesting that the IPA1 may directly activate the expression of SNAC1.SNAC1, a transcriptional factor belonging to the NAC family, regulates ROS homeostasis and confers drought tolerance in transgenic plants . In addiromoters . Bioinfors [IPA1  and founSNAC1. The IPA1 directly binds the A1 promoter region of SNAC1  after fusion with an N-terminal MBP tag. MBP-IPA1 bound GTAC motif labeled probes and formed DNA-protein complexes. Migration then decreased under increasing doses of competitive probes. The fusion protein could bind to the probe2 and probe4.Moreover, the specific binding of the fusion protein toprobe2 and probe4 was eliminated by addition of unlabeled competitors  staining to qualitatively detect H2O2 accumulation. The IPA1-Cas9 strain exhibited more H2O2 accumulation than the WT strain , three APX-family genes , a POD1, POX22.3and Cu/Zn-SOD, were expressed less in IPA1 knockout plants than in WT plants under drought conditions   plants survived under drought treatment , three APX-family genes , a POD1 and Cu/Zn-SOD, were highly expressed in IPA1-OE plants than in WT plants under drought conditions , larger panicles and higher grain weight [IPA1 knockout mutants to characterize the role of IPA1 in drought stress, and found that knockout of ipa1 significantly decreased rice drought tolerance at the seedling stage. The mature IPA1-Cas9 plants demonstrated dwarfism and more tillers, shorter and narrower flag leaves, and shorter panicles compared with WT plants. Previous studies have shown that overexpression of IPA1 decreases tiller number and yields a strong stalk [IPA1 is most highly expressed in the roots of seedlings, and knocking down IPA1 may affect root development and thus decrease the soil water uptake capacity and tolerance to drought stress.Drought stress is an important factor affecting crop production . Drought numbers . IPA1/Osn weight . In thisng stalk , 42. IPAOsbZIP23 plays a key role in drought tolerance [OsbZIP16 and OsbZIP71 positively regulate drought tolerance and the ABA signaling pathway [SNAC1 increases drought tolerance in rice [OsNAC2 regulates the drought stress response and ABA-mediated response [OsNAC52 is highly sensitive to ABA and increases drought tolerance in rice [WRKY transcriptional factors play important roles in regulating the abiotic response in plants [OsWRKY47 mutants are more sensitive to drought than wild type [OsWRKY30 in rice significantly increases drought tolerance [IPA1-Cas9 plants  . Howevernts Fig. f. In addnts Fig. e.IPA1 decreases drought resistance in rice seedlings and overexpression of IPA1 increases drought tolerance in rice. The IPA1 regulate the drought tolerance by affecting reactive oxygen species (ROS) content in rice. The Yeast one-hybrid, dual-luciferase and EMSA analyses indicated that IPA1 directly activates SNAC1 expression and directly affects tolerance to drought and oxidative stress through the regulation of ROS homeostasis. Our findings may have application value in increasing the drought resistance of rice.In summary, our results indicated that the knockout of Oryza sativa” materials in this study.The study protocol complies with relevant institutional, national, and international guidelines and legislation. We have permission to collect “Additional file 1: Fig. S1. (A-G) Gene expression associated with the drought tolerance pathway.  Interactions between IPA1 and the promoter fragments of OsNAC10 and OsNAC52, shown with yeast one-hybrid assays. Data are means ± se (n = 3). Statistical significance was determined by Student’s t-test. *, P < 0.05; **, P < 0.01. Fig. S2. Gene expression analysis of IPA1 in WT and OE lines. Data are means ± se (n = 3). Statistical significance was determined by Student’s t-test. *, P < 0.05; **, P < 0.01. Table S1. Primers used in this study.


JCI, Sena et al. developed a gene signature indicative of high AR activity to predict patient response to BAT, including a decline in both serum prostate-specific antigen (PSA) and tumor volume. Preclinical models showed that AR-mediated suppression of MYC, known to drive PC, was associated with decreased cell growth following SPA treatment. Because BAT eventually leads to resistance, the authors tested cycling between SPA and AR antagonism in a patient-derived xenograft and observed a delay in tumor growth. These findings represent a major step toward the informed use of BAT for advanced PC.Androgen deprivation therapy (ADT) is the longstanding treatment for advanced prostate cancer (PC) because androgen receptor (AR) is the key therapeutic vulnerability for this disease. Bipolar androgen therapy (BAT) — the rapid cycling of supraphysiologic androgen (SPA) and low serum testosterone levels — is an alternative concept, but not all patients respond and acquired resistance can occur. In this issue of the  Because androgen receptor (AR) signaling promotes growth and survival of prostate cancer (PC), blocking AR activation has been the cornerstone of treatment for more than 70 years. Androgen deprivation therapy (ADT) decreases the synthesis of the two major AR ligands, testosterone and dihydrotestosterone (DHT) using luteinizing hormone-releasing hormone (LHRH) agonists or LHRH antagonists. Despite initial therapeutic benefits, the disease inevitably progresses to an incurable stage termed castration-resistant PC (CRPC). This ultimate stage arises through a variety of mechanisms that promote persistent or reactivated AR signaling . This single arm, phase II clinical trial enrolled patients with metastatic CRPC whose cancer progressed on an ARSI and treated them with BAT for 12 weeks, followed by a combination treatment of BAT and the anti-PD1 agent nivolumab , which is highly expressed in PC. Further, a PDX that responded to SPA, as indicated by decreased tumor volume, showed decreased MYC. Similarly, patients who responded to BAT exhibited a larger decrease in MYC compared with nonresponders. Additionally, patients with decreased MYC also correlated with those that had higher AR activity before treatment . Althougpromotor .While SPA-mediated suppression of MYC is a leading proposed mechanism underlying BAT response, studies in preclinical models have implicated alternative mechanisms, including impaired DNA licensing, which is a process where high levels of ligand-stabilized AR bind to the origins of DNA replication and promote early arrest in S-phase . AdditioHSD3B1 leads to increased intratumoral DHT levels and promotes resistance to ADT and abiraterone treatment ) than men whose cancer had progressed on abiraterone  . Those tMW is a potential biomarker that may stratify responders from nonresponders; however, findings should be validated in an independent patient cohort. Although BAT therapy has the potential to improve the outcome of patients with metastatic CRPC while preserving good quality of life, treatment is not risk free and does not work for all patients. Therefore, BAT should not be used outside of a clinical trial, especially in combination with other therapies. Larger and randomized clinical studies are needed in the future to validate and determine the best way to integrate BAT into metastatic CRPC treatment algorithms.The Sena et al. study identified high AR activity as a requirement for clinical response to BAT, which is associated with downregulation of MYC. ARA


Current evidence demonstrates that few patients complete anterior cruciate ligament reconstruction rehabilitation according to evidence-based guidelines. It is important to investigate the viewpoints of our patients to identify patient-reported barriers and facilitators of anterior cruciate ligament reconstruction rehabilitation. Qualitative analysis can provide insight into potential methods for improving the delivery of rehabilitation services.In this qualitative study, utilising a social constructionism orientation, viewed through the social phenomenological lens, three focus groups were conducted with individuals 1–20 years post anterior cruciate ligament reconstruction . Utilising a semi-structured interview guide, participants were asked about their experiences during anterior cruciate ligament reconstruction rehabilitation. Focus groups were recorded, transcribed, and coded using an inductive semantic thematic analysis methodology.Five organising themes were identified (consisting of 19 sub-themes) to provide a framework to present the data: psychological, physiological, rehabilitation service, rehabilitation characteristics, and interaction with others. Each theme details aspects of rehabilitation, such as exercise delivery, informational support, frequency, and duration of care, kinesiophobia, weight management and interactions with teams and coaches, which present barriers or facilitators for patients to adhere to and participate in rehabilitation. Example quotes are provided for each theme to provide context and the patient’s voice.This qualitative investigation identified key aspects of a patient's rehabilitation in which they encounter a variety of barriers and facilitators of ACL reconstruction rehabilitation. These aspects, such as the rehabilitation characteristics, service delivery, psychological and physiological factors, and interactions with others, were consistently identified by this cohort as factors which affected their rehabilitation. The themes may provide targets for clinicians to improve rehabilitation and deliver patient-centred care. However, the themes must be evaluated in future trials to assess whether interventions to remove barriers or enhance facilitators improves subsequent outcomes such as return to sport and re-injury rates.The online version contains supplementary material available at 10.1186/s13102-022-00499-x. A typical anterior cruciate ligament (ACL) reconstruction rehabilitation lasts approximately 12 months before return to sport . CurrentAs a result, it is important to seek the viewpoints and investigate the experiences of our patients ACL reconstruction rehabilitation to gain insight into potential methods for improving the delivery of rehabilitation services. Previous research has provided evidence on the key role the treating health practitioner plays in setting an appropriate rehabilitation environment to reduce treatment-related barriers and enhance rehabilitation facilitators . ThroughQualitative methodologies, such as focus group analyses, are an appropriate methodology to investigate patients’ barriers to and facilitators of rehabilitation. Qualitative methodologies enable a more complete picture of a person's experience than quantitative research alone . Whilst This qualitative study utilised a social constructionism orientation and is viewed through the social phenomenological lens . ConstruAt the end of the survey , particiForty-two potential participants were contacted via email, with 20 consenting to participate in the focus group. Participants completed an online survey to collect personal, injury, sport, and demographic information. Participants were then allocated into one of three focus groups, based on availability and personal demographics, to create heterogeneous groups based on age, gender, injury, sport level and type to facilitate variations in personal experiences.Each focus group was allocated 6–8 participants and was estimated to last no longer than 60 min. Each participant was provided with an explanatory statement and signed a consent form informing them of the purpose, requirements, ethical considerations, and their rights in undertaking the research. The project lead (AW) conducted the focus groups at the University guided by a semi-structured interview guide  has extensive knowledge and experience within qualitative research methodology and thematic analysis. All authors assisted in reviewing and defining themes to check for consistency and stability and producing the report.We conducted three focus groups with six or seven participants, with a total of 20 individuals 1–20 years (mean 6.5 years) post ACL reconstruction. Focus groups lasted between 65 and 72 min. Each group consisted of a mix of genders , age ranges (19–51), sports, concomitant injuries, and participation levels. Twenty-five percent of participants had returned to their previous level of participation, and 85% reported having ongoing problems with their knee. All participants returned to a lower level of competition, changed, or did not return to sport due to factors relating to their knee, except participants 16 and 19 who returned to a lower level of competition due to other factors not related to their injury. When asked about their return to sport, participants reported that fear of movement (kinesiophobia) or reinjury and ongoing symptoms were the primary factors that affected their ability to return to their previous level of sport. Details of the selected participants are presented in Table Five organising themes were identified as key aspects of rehabilitation that present barriers and facilitators of rehabilitation adherence and participation on a patient’s journey back to sport. The research team developed a visual framework representing each theme as influencing factors of a patient's rehabilitation journey to return to sport Fig. . The orgParticipants detailed psychological factors which impacted their rehabilitation. Four subthemes were identified: (1) the participant's expectations for rehabilitation, (2) the impact of kinesiophobia and fear of re-injury on rehabilitation, (3) the difficulties in staying motivated throughout rehabilitation, and (4) the need for support from clinicians, friends, family, their team, and external sources.Most participants expected a 12-month recovery but underestimated the effort required in completing rehabilitation to a sufficient standard and intensity to address post-operative deficits. They felt health practitioners failed to inform them of the possibility of ongoing pain and other injuries. However, they believed that physiotherapists are in the best position to set realistic expectations with their patients due to the ongoing relationship and early input . As explained by one participant, "If they were to see a physio beforehand, maybe they would have an understanding of what you've got to do here and that it's going to be a longer journey because if those expectations are, I guess, worked out beforehand, you're less likely to have that disappointment or that depression and things that go on after surgery” (participant 20).Participants consistently reported that exposure to situations associated with their injury, such as jumping and change of direction, were the hardest to overcome. However, repetition and controlled exposure to these situations aided their ability to overcome their fears. As explained, “just making it more sport-specific, just recreating some of those scenarios that are scary. So, make sure you're comfortable with what you're doing and relate it into your sport” (participant 7).Some participants lost motivation to complete rehabilitation due to not feeling supported in their return to sport ambitions. Slow progression and other priorities through the mid-stages of rehabilitation made it challenging to maintain motivation in completing rehabilitation; however, striving for and achieving key milestones and goals assisted in maintaining motivation over the long term. For example, "that one stage where it's like, yes, you can run for as long as you can. That was super … It was motivating” (participant 15). Exposure to athletes who had returned to high-level sport also increased motivation.Having a supportive team to guide you through surgery, recovery and rehabilitation aided in achieving a successful outcome. Support could be from external sources, such as online support groups, friends and family or the treating health practitioners. As explained by one participant, "one thing that's come out of just hearing everything today is that such a massive part of rehab is between the ears… that mental side and it all starts from the minute you walk into the door to your surgeon, and then you pick your physio and that person, and how they understand what you are going through” (participant 1).Participants mentioned physiological factors which impacted their rehabilitation; three subthemes were identified. These are: (1) older individuals feeling discriminated against, (2) post-operative weight management, and (3) the challenge of pain during rehabilitation.Unlike younger individuals, older individuals felt surgeons and physiotherapists failed to consider their return to sport goals. As detailed by one participant, “he must have said five, six times, well, at your age, women your age tend to. Do you want to just do Pilates? Do you want to just walk on the beach, because if that's the case, you don't need your ACL done? And I felt very patronised" (participant 2). Older individuals also felt it was slower and harder to recover from the surgery.Participants were seeking alternative means to exercise and dietary information to adjust to post-surgical inactivity. Many participants reported weight gain hindered rehabilitation and failed to lose it long term. As suggested by one participant, “I think a nutrition plan will help as well. Like you said, gaining weight is a potential issue…. And you're just like, I don't even know how to eat at all. I think that is really important” (participant 13).Participants reported persistent pain and complications such as patellofemoral pain, delayed rehabilitation progression and reduced adherence. "The fear, for me, was that I couldn't get rid of kneecap pain for so long and whether that was ever going to go away” (participant 19).Factors related to the delivery of the rehabilitation service were identified, resulting in five subthemes. These are: (1) challenges during their initial utilisation of health services, (2) difficulties in accessing health care, (3) the factors which influence the frequency and duration of supervised rehabilitation and (4) the utility of group rehabilitation and (5) telehealth as modes of service delivery.Initial interactions within the health care system were reported to present barriers to rehabilitation progression through delays in diagnosis and a failure of first contact practitioners to hear patient concerns. Many participants had similar stories, “I found it was kind of disconcerting when everyone's going around sharing their ACL stories that like half of us, when we were initially diagnosed was saying, oh, it's just bone bruising, like, oh, it's just a sprain." (participant 15). Participants also had a desire for a plan that encompassed a variety of options for their care to prepare for the entirety of rehabilitation adequately. Remarkably few participants completed any form of prehabilitation, but it was highly valued in those who did.Having the time to travel to and attend appointments was a common barrier for participants. Access issues were particularly evident in the early phases due to post-operative driving restrictions and others with high family and work commitments. “I think probably the difficulty for me was being a mum of two, working full time…. That was my difficulty” (participant 17).As rehabilitation progressed, the ever-increasing cost became a burden to participants and may result in early cessation of care; "So, I think the biggest barrier is access to physio being more affordable in Australia…. I'm at the start of my journey, that could be quite expensive over nine months for me to afford” (participant 6). Participants who ceased rehabilitation early (before six months) reported wishing they had continued longer to avoid long term problems. Some participants reported periodic review in the later stages of rehabilitation, at the recommendation of the physiotherapist, made it difficult to maintain motivation and overcome physical impairments, build confidence and physical capacities for return to sport.Group rehabilitation was widely supported across participants to facilitate rehabilitation progression by developing physical capacities while also providing support and motivation through interaction with others. One patient noted, "Just to be part of a group of people that we had gone through the same thing, just for accountability and motivation because you lose your self-confidence until you can really get going again” (participant 8).articipant 10).Telehealth was accepted as a mode of service to reduce financial and travel burdens but only in combination with in-person appointments to monitor pain, exercise technique, overcome kinesiophobia and deliver hands-on therapies. As one patient expressed, “I think there're some things that you could've done fine with telehealth that probably would've helped with the cost of some of it and the access…. but like some of the stuff that I had to do with my physio, I don't think I would ever have been able to do it if I didn't feel they were right there to catch me if I fell off a block. I just wouldn't have done it. I don't think” (pParticipants spoke about barriers and facilitators they encountered during rehabilitation sessions and interactions with their physiotherapist. The four subthemes identified were: (1) difficulties in completing exercises independently, (2) the desire for informational support, (3) the need for clear and progressive goal setting and reassessment and (4) the relationship with their physiotherapist built on trust and collaboration.Participants consistently reported difficulty completing their rehabilitation as prescribed due to therapists providing unclear instructions and excessive use of technical language. As one participant described, “I probably didn't feel like I was getting very good instruction as to what to do… It wasn't that I wasn't willing to commit to the time, it was I just wasn't sure what I was supposed to be doing” (participant 19). However, participants highly valued being informed of the reason for exercise selection and a clear path for progression. To enhance exercise adherence, they recommended using exercise prescription applications and the therapist considering individual circumstances such as work, family, and exercise competency. Further, participants often expressed that the late stage of rehabilitation was poorly executed and failed to expose them to training to prepare them for a return to sport; “I think the other barrier for physio is once you get to nine months, and you're doing most of your strengths pretty equal, is that specific skills that you want to be outside running, changing direction, and you can't do that in a small clinic, and that's kind of where I left once, I wanted to be outside” (participant 7).Due to the long rehabilitation process, participants consistently reported seeking external sources of information to assess their progress, answer questions and provide motivation. They did express concern over verifying external sources of information. They recommended therapists “not give all of the information the first time you see someone, because it's just too much. It's like a drip-feed, and then building on it each time” (participant 5).Participants highly valued the process of collaboratively setting and achieving relevant goals and milestones but reported that it was poorly executed  or never provided to them; "’Here's where you are. This is where you're going. These are our checkpoints along the way.’ And then let's talk about it, and see if you're happy with it, and if we're there and if not, why not? What are we going to do about it to get you to where you should be? I mean, that didn't happen to me, and I thought it should've done” (participant 1). Setting non-clinical goals  should also be considered.Many participants described how a strong therapeutic relationship built on trust, knowledge and support enhanced rehabilitation and guided them through a lengthy rehabilitation process. For example, one participant stated, “it's the relationship that you build which is based on trust. You trust that that physio will get you there, and the physio has also got to trust that you're going to do your job, and you're not going to let the physio down. So, it's building that” (participant 2). They also expressed that the selection of the wrong therapist can significantly hinder rehabilitation.Participants spoke on how their interactions with others or the wider community impacted their rehabilitation. Three subthemes were identified: (1) the ability of the surgeon to influence the plan for care and rehabilitation, (2) the importance of supportive family and friends and (3) the desire to stay involved with their team.Some participants reported a positive, motivating, and supportive interaction enabled rehabilitation; however, some initial surgeon interactions were perceived as impersonal, negative, and demotivating, which inhibited recovery. The surgeon is in a highly influential position, “whatever they say, you believe because…. you put your trust in them…. they need to build some comfort and warmth inside, warm and fuzzy to make you feel that it's going to be okay” (participant 1). Participants also reported never being recommended to undertake a period of prehabilitation from their surgeon.Participants valued friends and family who facilitated rehabilitation through offering transport, encouragement, and supervision during rehabilitation. However, they often felt that others failed to understand the significance of the injury; “I think people around you didn't understand either, isn't it? Because it's like when you hurt your back because it's not a big gaping wound and people can't see it, they don't… Not as much empathy” (participant 11).The opportunity to stay involved with their team through coaching and support roles was highly valued by participants. They often felt isolated from their team when unable to participate in training and games. As one participant detailed, “I was a little bit isolated. Because the team, they're doing a real intense workout and you're like, I'm just going to use some TheraBand’s and hope for the best” (participant 10).The current study investigated the patient-reported barriers and facilitators of ACL reconstruction rehabilitation. The five organising themes identified and associated subthemes provide the clinician with a patient’s perspective of the barriers encountered as patients pursue their activity and sport goals. The specific themes, contexts and examples identified during this qualitative investigation provide targets for clinicians to improve the rehabilitation experience and facilitate adherence to evidence-based rehabilitation.Patients’ psychological response to injury, surgery and ongoing rehabilitation is heavily influenced by the practitioners involved in their care. Patients typically have high expectations for returning to sport that is often not met, highlighting the importance of setting clear expectations early in rehabilitation , not onlConsistent with previous literature, kinesiophobia and fear of re-injury were significant barriers to completing rehabilitation and returning to sport . KinesioIn some patients’ referral to a sports psychologist may be appropriate.Several factors influenced motivation to participate in rehabilitation. Common factors included the lengthy rehabilitation process, competing life demands, time commitment, rising costs, setbacks, or plateaus in rehabilitation. As self-motivation has been linked to home exercise completion , ongoingACL reconstruction may result in a vicious cycle of injury, sedentary lifestyle, weight gain and increased risk of musculoskeletal injury and cardiovascular disease . ImpairmConsideration of the goals and return to sport aspirations of older individuals need to be respected. Despite their age, they often had the same goals and aspirations to return to sport as their younger counterparts. However, older individuals were often told not to play sport again based on their age, creating a barrier to applying themselves to rehabilitation and meeting physical benchmarks, which, regardless of age, will enhance reaching long-term function . The majPatients are seeking a plan which encompasses all phases of rehabilitation. A clear area of deficiency within the participant's rehabilitation was the lack of early physiotherapy input to prepare physically for surgery and set expectations and goals for rehabilitation . This isIn contrast, others feel they did not need frequent reviews and felt prepared to continue working towards their mid-stage goals independently. In the later phases, participants are often finding it hard to complete rehabilitation due to lack of confidence, technical exercise prescription knowledge, failure of the physiotherapist to progress the rehabilitation to sports-specific activities and rising costs. In combination with the competing demands of work and family, it potentially results in early cessation of supervised rehabilitation.In our cohort, most participants either failed to complete rehabilitation or did not participate in any form of sports-specific rehabilitation, which is consistent with previous literature . All parEffective exercise prescription to achieve appropriate functional levels before return to sport is an essential component of a successful ACL reconstruction rehabilitation . As demoFinally, despite recent evidence questioning the validity of return to sport tests , 37, a fThe initial interactions with the surgeon play a role in preparing for rehabilitation. Facilitating a supportive environment builds confidence and motivation for rehabilitation and cohesive messaging across the treatment team. Negative interactions with family and friends, team and coaches, and the media may create barriers to rehabilitation. On the other hand, supportive family and team environments that facilitated rehabilitation by encouraging exercise completion, allowing ongoing involvement with the team, and drawing motivation from public sports figures enhanced their rehabilitation compliance.There are several limitations to the current study. The identified factors are a representation of the perceptions and opinions of the individuals involved in the research. These may not be able to be extrapolated or be representative of a different population or context. The identified themes were unable to be weighted; as such, we cannot determine the strength of one of them over another to influence a patient’s rehabilitation. The cohort included a wide range of participants, as such perspectives may differ in a more homogeneous population based on age, gender or return to sport goals. On average, participants were 6.6 years post ACL reconstruction introducing a recall bias due to the relatively long period since active rehabilitation. The analysis and coding for themes were completed by one researcher, influencing the trustworthiness of the thematic analysis. Finally, the semi-structured interview guide and coding were guided by a-priori themes based on previous literature, creating bias within the coding structure. Some participants also had a prior relationship with the researchers. Future research should confirm these factors, explore the weighting of these factors, and investigate the effect of implementing a tailored rehabilitation program addressing the barriers and promoting rehabilitation facilitators on patient outcomes.There are many reasons why patients may fail to adhere to or participate in rehabilitation, which may be a key factor in high re-injury and low return to sport rates after ACL reconstruction. This qualitative investigation identified key aspects of a patient’s rehabilitation in which they encounter a variety of barriers and facilitators of ACL reconstruction rehabilitation. These aspects, such as psychological and physiological factors, the rehabilitation service, rehabilitation characteristics, and interactions with others, were consistently identified by this cohort as factors that affected their rehabilitation. The themes may provide targets for clinicians to improve rehabilitation. However, the themes must be evaluated in future trials to assess whether interventions to remove barriers or enhance facilitators improves subsequent outcomes such as return to sport and re-injury rates.Additional file 1. Focus group semi-structured interview guide, the semi-structured interview guide used in each focus group as referenced on line 98 of the manuscript.Additional file 2. Themes and additional verbatim quotes, additional verbatim quotes from each of the identified themes and subthemes as referenced on line 148 of the manuscript.


The optimization produced NaOH and CR levels of 10% and 2%, respectively, with high desirability of 71.4%.One of the primary causes of the low mechanical properties of rubberized concrete is the weak bond between crumb rubber (CR) and hardened cement paste. Many CR pretreatment techniques have been researched in an attempt to mitigate this problem. The NaOH pretreatment method is one of the most widely used, although the reported results are inconsistent due to the absence of standardized NaOH pretreatment concentrations and CR replacement levels. This study aims to develop models for predicting the mechanical and shrinkage properties of NaOH-pretreated CR concrete (NaOH-CRC) and conduct multi-objective optimization using response surface methodology (RSM). The RSM generated experimental runs using three levels  of both NaOH pretreatment concentration and the CR replacement level of fine aggregate by volume as the input factors. At 28 days, the concrete’s compressive, flexural, and tensile strengths , as well as its drying shrinkage (S), were evaluated as the responses. The results revealed that higher CR replacements led to lower mechanical strengths and higher shrinkage. However, the strength loss and the shrinkage significantly reduced by 22%, 44%, 43%, and 60% for CS, FS, TS, and S, respectively, after the pretreatment. Using field-emission scanning electron microscopy (FESEM), the microstructural investigation indicated a significantly reduced interfacial transition zone (ITZ) with increasing NaOH pretreatment. The developed RSM models were evaluated using ANOVA and found to have high R The ever-increasing world population raises transportation demands, which lead to increased automobile production. This has also resulted in an unprecedented increase in global waste tire generation ,2,3. It Crumb rubber (CR) is produced from waste tires using a milling process that results in rubber particles ranging in size from 0.425 to 4.75 mm. The nature of the particles is determined by the temperature and milling method employed  . Many reDespite the observed improvements in properties of concrete due to the incorporation of CR, it is universally acknowledged that mechanical strengths are adversely affected. Among the reasons given for the decline in strength with an increase in CR is its lack of proper bonding with the hardened cement matrix ,26,27,282O2, CaCl2, H2SO4, Silane, and KMnO4_NAHSO4). However, they concluded that the use of water washing as a form of CR pretreatment performed much better than all the chemical pretreatment methods, and the improvement using the chemical pretreatment is not worth the cost. Furthermore, Safan et al. . Compared to the mixes having untreated CR (M5 and M3), there was a 24% and 32.7% increase in the tensile strength at 5% and 10% NaOH pretreatment (M6 and M2), respectively. This is in agreement with the reported enhancements of 3–36% in the splitting tensile strength reported from previous studies on NaOH pretreatment of CR . Hence, The result of the drying shrinkage is shown in A FESEM investigation was carried out to assess the influence of the NaOH pretreatment on the CR and how it affects the concrete’s properties. On the other hand, The rate of strength reduction increases with an increase in CR replacement levels for all the NaOH pretreatment concentrations. This is due to the soft nature of the CR particles, which act as artificial flaws within the concrete. However, the enhancing effect of the NaOH pretreatment can be observed from the mechanical strength results where all samples with higher NaOH concentration exhibited higher strengths than samples containing the same CR content but with lower NaOH pretreatment concentration.RSM is used to develop models for response prediction as part of the study data analyses. The independent variables evaluated as input factors from the beginning are the NaOH pretreatment concentration and the CR replacement levels of fine aggregate by volume. The mechanical strengths  and the drying shrinkage (S) were the responses under consideration (output factors). Equations (1)–(4) present the developed response surface-based predictive models. These models are developed from the empirical data generated during the earlier experimental investigations. The models presented here are in coded factors. By default, high levels of the variables are encoded as +1, while low levels are encoded as −1. The coded equations may be used to identify the relative relevance of the factors by comparing their coefficients. As input factors, A and B represent the NaOH concentration and CR replacement levels. Quadratic models were found to be more suitable for the responses except for the FS that was fitted with a linear model.2 are significant model terms in CS and TS models. A and B are significant model terms in the FS model. The significant model terms are A, B, and A2 in the S model. Furthermore, one of the indicators for an accurate model is an insignificant lack of fit p-value. The lack of fit p-value is used to assess the fitness of the developed models, and a value of more than 5% is desirable. Hence, in this case, all the developed models have a lack of fit p-value of more than 0.05, indicating the good fit of the models.The next stage in the RSM analyses is model validation. The developed models were validated using ANOVA at a 95% confidence level (5% level of significance). Hence, any model or model term having a probability of less than 5% is statistically significant. The result of the ANOVA analysis is presented in 2 (coefficient of determination) value as one of the model validation parameters shown in 2 values of 0.9709, 0.7872, 0.9677, and 0.9803 for the CS, FS, TS, and S indicate a high degree of correlation between predicted and experimental results and the adequacy of the models in predicting the responses with high accuracy [Similarly, the quality of the developed models was assessed using the Raccuracy . FurtherOne of the model diagnostic tools used to assess the quality of the developed models is the predicted vs. actual graph. The graphs depict the distribution of data points along the line of fit, and the linearity of the points around the lines of fit defines the model’s quality. The plot for all the developed models is presented in (a) parts of Another advantage of RSM is the development of the 3D response surface diagrams as shown in the (b) parts of In order to determine the best amount of the NaOH concentration and the CR content that can give the most desirable properties of the NaOH-CRC properties under consideration , optimization was performed as part of the RSM analyses. Multi-objective optimization is more suitable as most real-life situations involve finding optimal solutions simultaneously for several objective functions. The goal, in this case, is to determine the optimal levels of the input factors that will yield optimal values of the responses simultaneously without compromising any.The procedure begins with assigning the goal and importance to the input and output variables, followed by running the system and receiving the solutions as the optimal values of all the variables and the desirability index for the optimization. The desirability index gives the level of accuracy of the optimization process on a scale of 0 to 1 (0 to 100%). In this case, the optimization criteria are presented in The optimization solution is presented in The optimization was experimentally validated by producing a mix containing the optimized levels of the input factors (CR and NaOH). Three samples were cast for each of the four properties considered as the responses  in the RSM analysis. The samples were tested after 28 days and the results are presented together with the predicted results in It was found that an increase in CR replacement of fine aggregate adversely affects the CS, FS, TS, and S of the NaOH-CRC. However, the rate of strength loss is significantly reduced with NaOH pretreatment. Increases in NaOH pretreatment concentration resulted in a 22%, 44%, and 43% decrease in strength loss for CS, FS, and TS, respectively.The pretreatment significantly reduced the shrinkage. A 63% decrease was reported between a mix containing 10% untreated CR and 10% NaOH-CR. This is due to the enhanced reactivity of the CR with NaOH pretreatment, which results in improved interaction and production of cement hydration products and densification of the ITZ.The FESESM investigations revealed a significantly reduced ITZ with an increase in the NaOH pretreatment. The pretreatment removed the hydrophobic zinc stearate on the CR surface, converting it to sodium stearate, which was washed off during the pretreatment, making the surface more hydrophilic, allowing for better bonding with cement paste and other cement hydration products.2 values of 0.9709, 0.7872, 0.9677, and 0.9803 for the CS, FS, TS, and S, respectively. The optimization resulted in an optimal value of 10% and 2% NaOH and CR levels, respectively. At the optimal levels of the input factors, the system predicted values of 33.9 MPa, 6.0 MPa, 3.6 MPa, and 0.04% as the optimal values of CS, FS, TS, and S, respectively, at a desirability index of 71.4%.Response surface-based models were developed and validated using ANOVA. The models were assessed to be strong for having RThe performance of rubberized concrete has significantly improved as a result of a better interaction between the CR and the hardened cement paste due to the NaOH pretreatment, and it can now be recommended for structural use in the construction of elements such as foundations.This research aimed to determine the effect of NaOH pretreatment of CR on the mechanical strengths, ITZ interactions, and drying shrinkage of CRC and develop predictive models and perform optimization using RSM. At the end of the research, the following conclusions can be drawn:


With the popularization of the Internet and medical knowledge, more and more people are learning about allergic rhinitis (AR) on the Internet.This study aims to analyze the epidemiological characteristics and online public attention to AR in Wuhan, China, utilizing the most popular search engine in mainland China and meteorological data of Wuhan.To study the Internet attention and epidemiological characteristics of AR in Wuhan, the search volume (SV) of “Allergic Rhinitis” in Mandarin and AR-related search terms from 1 January 2014 through 31 December 2021 were recorded. For user interest, the search and demand data were collected and analyzed.The yearly average Baidu SV of AR in both Wuhan and China increased year by year but began to decline gradually after the COVID-19 pandemic. Baidu SV of AR in Wuhan exhibited significant seasonal variation, with the first peak was from March to May and the second peak occurring between September and October. Correlation analysis revealed a moderate positive correlation between the monthly average SV of “Allergic Rhinitis” and “Mites” and “Mites + Pollen Allergy” in Wuhan, a weak positive correlation between the monthly average SV of “Allergic Rhinitis” and “Pollen Allergy,” and a positive correlation between monthly SV of “Allergic Rhinitis” and the meteorological index of pollen allergy (MIPA).The attention given to the topic on the internet, as measured by the search volume, was reflective of the situation in Wuhan, China. It has the potential to predict the epidemiological characteristics of AR and help medical professionals more effectively plan seasonal AR health education. Allergic rhinitis is one of the most common allergic diseases in China . AR is aAvoiding exposure to inhaled allergens can relieve the symptoms and reduce the incidence. Wearing face masks is an effective way, which most people have been doing since the COVID-19 pandemic. Recent research has shown that COVID-19 lockdowns have been proposed as contributing to decreasing symptom severity in patients with AR . At presWith the popularization of Internet devices and health education, mobile phones and computers have become a very convenient way to obtain medical information and consult on health problems . Many stPollen and dust mites are the most common allergens associated with AR in Wuhan , 20. HowIn this study, we collected “Allergic Rhinitis” and various allergen search data in Wuhan as online public attention toward allergic rhinitis. This study aimed to analyze the AR-related search trends and online public attention in the Wuhan area, as well as the people's demand. We also gained meteorological data in Wuhan to analyze the relationship between online attention toward AR and the MIPA, partly verifying the importance and feasibility of developing pollen concentration prediction. Given the inadequacy of traditional methods and the lack of data sources, Internet search data is able to provide new insights into the epidemiological characteristics of AR, improve the detection and prediction of AR, and track public interest in multiple health topics. Thus, medical practitioners can fully utilize Internet data to track AR prevalence and patients' needs to create related health care policies and health education.This study mainly analyzed the temporal search trends of AR and AR-related terms in Wuhan. To reduce the results bias caused by different language habits, we selected the most frequently used keywords related to AR on the web, including “Allergic Rhinitis” and AR-related search terms, “Pollen Allergy,” “Dust Mites,” “Mites,” “Dust Mites Allergy,” “Mites Allergy,” and “Mites Allergy + Pollen Allergy.” And the daily search volume of the above terms was counted from 1 Jan 2014 to 31 Dec 2021 through the Baidu Index platform , 18, 21.We obtained the monthly basic level of MIPA in Wuhan from the Meteorological Industry Standard of the People's Republic of China–QX/T324-2016 Meteorological Index of Pollen Allergy  issued bBesides, we also collected user demand graph data from the Baidu Index platform, which can partly and intuitively reflect what AR patients were usually concerned about.The main variables examined were the search volume of AR, AR-related terms in Chinese and MIPA from 1 Jan 2014 to 31 Dec 2021.Normality Test To verify the distributive normality of a data set, we used the Shapiro-Wilk test plus a graphical check of histograms and quantile-quantile diagrams.P values.Pearson and Spearman Cross-Correlations, when the data sets were normally distributed, the Pearson correlation R was used; otherwise, the Spearman correlation R was used. The correlation strength was assessed independently of the P values were used as a continuous measure of the strength of evidence against the null hypothesis. There were three independent hypotheses tested on a set of data in our study, namely the correlation between the monthly average SV of “Allergic Rhinitis” and “Mites,” “Allergic Rhinitis” and “Pollen Allergy,” “Allergic Rhinitis” and “Mites + Pollen Allergy” in Wuhan from 2014 to 2021, with P values corrected according to Bonferroni correction.Software SPSS 26.0  was used for data analysis.From 2014 to 2017, the Internet attention to AR in China and Wuhan both continued to rise . The yeaWith monthly SV as the ordinate and the month as the abscissa, the Baidu users' Internet attention to AR in Wuhan reached its obvious peaks from Sep to Oct every year and small peaks from Mar to May every year . MeanwhiP < 0.001, 95% CI: , Considering people's awareness of dust mite allergens and different language habits, we collected the search volume of AR-related keywords that people might search for. It included SV of “Mites,” “Mites Allergy,” “Dust Mites,” and “Dust Mites Allergy” from 1 Jan 2014 to 31 Dec 2021 in Wuhan and China. Among them, the SV of “Mites” was the highest in both national and Wuhan data, while the SV of other keywords was very low and had no obvious correlation with AR SV , 4. So, P < 0.001, 95% CI: , P < 0.001, 95% CI: , Pollen is one of the most common allergens. Research shows  that airP < 0.001, 95% CI: , As a city located in central China, the most common allergens causing AR in Wuhan include both pollen and dust mites. Therefore, we analyzed the correlation between the monthly average SV in Wuhan of “Allergic Rhinitis” and the SV of “Mites + Pollen Allergy” , represeP = 0.236, 95% CI: ], 2015 ], 2016 ], 2017 ], 2018 ], 2019 ], 2020  and moderately correlated in autumn (Aug-Oct). The SV of the main spring airborne pollens in Wuhan, Moraceae and Salix, had obvious peaks in spring . InteresTo sum up, our study showed the trend characteristics of “Allergic Rhinitis” search volume are basically consistent with the results of previous epidemiological investigations , 33–35 aPollen-induced AR has attracted more and more attention to people in China. This study found a positive correlation between the monthly SV in recent years and the MIPA. Pollen concentration plays a key role in the outbreak of AR and predicting pollen concentration in advance is very important to control AR. However, there are very few cities in China to carry out pollen concentration predictions . Therefore, we select the MIPA instead of pollen concentration in Wuhan, which can reflect the real sensitization effect of pollen concentration on the human body. The positive correlation of AR Internet attention and the MIPA suggests that we can use the Baidu Index to develop a calculation model to predict the arrival and duration of pollen season, which is a real-time and simple method of self-health management for patients with AR. When the SV of “Allergic Rhinitis” begins to increase, which indicates the arrival of pollen season, and pollen-sensitized AR patients should be reminded to take active measures to prevent AR, such as wearing face masks or using medication. This will not only contribute to avoiding the onset of seasonal AR, reducing the pain of patients, but also help to save the expenditure of social medical resources. Of course, more studies are needed to confirm the relationship between SV of “Allergic Rhinitis,” MIPA in different cities and actual pollen concentration.Besides, we also collected user demand graph data, which can partly and intuitively reflect what AR patients were usually concerned about. As shown in the Demand Graph of allergic rhinitis, patients are most concerned about the therapy and symptoms of AR, and most AR patients search for “Nasosinusitis,” “Chronic rhinitis,” “Allergic conjunctivitis,” and “Eye itching.” Besides, the SV of related words, such as “Seasonal allergic rhinitis,” “Allergic rhinitis in children,” and “Can allergic rhinitis infect,” is increasing. As can be seen from the Demand Graph, many AR patients are still not cured or relieved and are looking for a radical cure. In addition, a considerable number of AR patients are suffering from nasosinusitis and allergic conjunctivitis at the same time. In general, people would like to search for medical information about AR more and more.Our results are based on Internet search data, which reflects the public awareness of AR in a comparatively objective way. However, research has shown that mass media have an impact on the search behavior of web users and play an important role in managing an infodemiology and conditioning the search behavior of web users , 37. ManThe main limitations of this study should be addressed. First, Baidu Index only analyzes search data from Baidu, not social media platforms or other search engines, and provides limited data. Moreover, the impact of mass media coverage on web users' behavior is difficult to assess and eliminate. And these search behaviors may be also influenced by the diagnostic ability of the consulted doctors, such as the general practitioners' ability to distinguish between allergic rhinitis and non-allergic rhinitis. Second, the primary users of search engines are young and middle-aged people, which may lead to an age bias. The Internet and smartphone penetration rates in economically developed areas are higher than those in non-developed areas, resulting in a certain degree of regional bias. But with the development of the economy and the popularization of the Internet, the age-bias and regional bias will gradually decrease. Third, whether predicting the arrival of pollen season or the attacks of AR based on Internet search data, there must be a lag. We still need to study the approximate lag time further, and then bring the results forward when making predictions. Furthermore, information about AR patients could only be based on age, gender, and regions, but information such as the users' age and gender in a certain region, socioeconomic status, ethnicity, and educational background could not be obtained. More studies are needed in the future to adequately demonstrate the role of big data in understanding the population's needs and in the surveillance of diseases.To the best of our knowledge, this is the first study that analyzes the epidemiological characteristics of AR in Wuhan as well as the correlation between MIPA and the prevalence of AR based on the Baidu Index. This is also the first web-based research on the association of the Internet search trends with the COVID-19 pandemic. In recent years, the number of active users of Baidu has been growing, so Baidu's big data has great potential in medical treatment and disease epidemic surveillance and will play a more and more important role.In summary, our study showed that Baidu Index data could reflect the real-world situation to some extent and has the potential to predict the epidemiological trends of AR. The Internet data can also be used by medical practitioners to monitor the prevalence of AR and the patients' needs, provide guidance to make disease-specific health care policies and health education, and optimize clinical consultations. Furthermore, developing a platform to predict pollen concentrations as well as the arrival and duration of the pollen season is an excellent method of prevention and management for AR patients. More importantly, keeping good personal hygiene habits and wearing face masks outdoors can help reduce the incidence and attacks of AR.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number (s) can be found in the article/supplementary material.YW and ZG collected and analyzed the data, discussed the detail, and wrote this article together. HL performed the statistical analysis. YX supervised the study, modified this manuscript, and was major contributor in writing the manuscript. All authors read and approved the final manuscript.This research was supported by the National Natural Science Foundation of China (No. 82071017), the Natural Science Foundation of Hubei Province (No. 2021CFB125), and the Fundamental Research Funds for the Central Universities (No. 2042021kf0093).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.