The study examined whether psychiatric/psychosomatic rehabilitation continues to have a better course of treatment for women than men.We compared the course of global symptom severity, health-related quality of life and functioning between admission and discharge in patients  at an Austrian psychiatric/psychosomatic rehabilitation clinic.Gender-specific differences in the course of treatment were all too small to be clinically relevant. The differences were smallest in the middle-aged cohort. However, at the time of admission, women reported a slightly higher symptom burden.Overall, the results show a gender-fair effectiveness of the rehabilitation. The new findings could be explained by changes in living conditions, gender roles, or better treatment methods. Psychosomatic rehabilitation focusses on the psychotherapeutic treatment of mental disorders in a stationary context with the goal to reduce symptoms and increase functioning and quality of life. Many studies have shown that psychosomatic rehabilitation shows better treatment effects for women than for men –3. This Gender differences are not only evident in the course of treatment; women and men differ in the severity of symptoms , as wellt(2258) = 2.251; p < 0.05, 95% CI , Cohen’s ds = 0.10. The most common diagnoses (main diagnosis) of patients were F30-F39 mood disorders (63.6%) and F40-F48 neurotic, stress and somatoform disorders (28.3%). At the time of admission, 1,116 (65.6%) of the patients were employed, 484 (28.4%) were unemployed and 102 (6.0%) were retired or had applied for a pension or were receiving rehabilitation or sick pay. Gender and age-specific differences with regard to diagnoses and occupational status (employment) are described in The present study is a retrospective analysis of data collected as part of the routine examination. The study analyses data from 2260 rehabilitation patients, with complete examination results  who were treated between July 2011 and January 2015. Depending on the outcome, measurements from 71 to 66% of the total patient sample are available. Missing measurements are mainly due to the clinic’s internal processes. The sample comprised 848 (37.5%) men and 1412 (62.5%) women. The patients were between 18 and 74 years old at the time of admission. Their mean age was 46.1 years . Details are given in Gender, age, diagnoses (i.e. the main diagnoses upon discharge) and information on the professional status (employment) were determined using the basic documentation of the hospital information system. Gender  was defined in terms of biological sex. Age referred to the chronological age (in years) at the time of admission. Diagnoses were classified using the ICD-10 .The routine examination survey assessed the general symptom burden, quality of life and functional ability (primary outcomes). General symptom severity was determined using the Symptom Checklist (SCL-90)  or the BThe study used a naturalistic one-group pre-post design without a control group. The analysis used data of patients who were treated at the psychiatric rehabilitation clinic Gars am Kamp in Austria. Patients answered the questionnaires in a computer assessment room in the presence of a trained professional. The self-report measures were assessed using the Hogrefe test system. This system provides a platform that administers standardized questionnaires licensed by Hogrefe. It provides a user-friendly surface and assures data integrity. The GAF was assessed during individual medical examinations.The analyses were approved by the ethics commission of the Karl Landsteiner University of Health Sciences (Nr: 1006/2021). We complied with the requirements of the current version of the Declaration of Helsinki . The patwww.pv.at) responsible for psychiatric/psychosomatic rehabilitation in Austria. Psychosomatic rehabilitation in Germany and psychiatric rehabilitation in Austria are very similar approaches to treat mental disorders. Both emphasize psychotherapeutic interventions, but also include psychopharmacological and various other complementary interventions, for instance excise and physical therapy. Both mainly treat patients with depressive or anxiety-related disorders. Further details on the treatment program can be found elsewhere “: n my view, the sentence does not fit well as an explanation for the effects of gender role in rehabilitation, since the individuals have already sought help and started rehabilitation. Or are there findings that men then take the treatment itself less seriously or make less use of it during inpatient treatment?- Page 4: “Women suffer more often […]“: This sentence seems in the wrong place, since it seems that it does not contribute to the linked arguments in the sentences before and after this sentence.- Page 6: I would recommend to put the G*Power analysis together with a more detailed description of the conducted analyses in the Analyses section. Especially the repeated-measure ANOVAs could be described more in detail.- Page 9: “The biggest effects were found in for functional ability […]”- Page 10: “[…] men showed the better course in this measure, which might be because […]”: Since the second half of this sentence is an interpretation, it should be moved to the discussion.- Page 24: Table 2 needs some revision in the section “Employment”. The percentage of employed people in the oldest WHO group is in the wrong line and is missing it’s percent sign.- The authors should point out in the limitations, that the data was obtained only from one clinic and therefore generalization is limited. Furthermore, they should discuss that the data of some patients is ten years old and gathered over a long period of time, where e.g. changes in the understanding of gender roles in the society could have changed slightly and therefore confounded the analyses.Reviewer #2: This is an interesting paper about the effects of gender on the treatment outcomes of inpatient psychiatric rehabilitation in Austria. The paper is fairly clear in the approach and analysis. The manuscript would benefit from a few changes for readability and clarity.Introduction*Please describe psychosomatic rehabilitation- how is this the same or different from psychiatric rehabilitation? It may be helpful to use either one term or the other- the term “psychiatric” is preferred to describe hospital treatment.* Please use rehabilitation interventions not rehabilitationsp.4 Consider mentioning the subjective nature diagnosis – are there studies that examine the effect of clinician gender on treatment outcomes?Method*There is some duplication in description of study design.*Please address why the BriefSCL and SCLwere both utilized and the comparability of results between them.*It would be helpful for the reader to explain the “Hogrefe” systemDiscussion*How are differences in symptom distress related to diagnosis?Is there an interaction effect of diagnosis and QoL?*It may be helpful to also consider measurement error for current or previous research findings. Is there gender bias in the standardized tools?*The statement “The present findings confirm that gender-sensitive treatment is possible, even if women are still more distressed than men upon admission.” Is not well supported by your research question or results. Rather, it seems to suggest that rehabilitation interventions are effective despite limited access to gender-sensitive treatment. It may also suggest looking at measurement tools differently to capture gender differences and/or the use of qualitative exploration to reveal gender differences.* There is also evidence that people in the age cohorts of younger and older adulthood may require age-specific treatment or gender-sensitive treatment based upon age.**********what does this mean?). If published, this will include your full peer review and any attached files.6. PLOS authors have the option to publish the peer review history of their article  digital diagnostic tool, AttachmentPLOS_2021.docxSubmitted filename: Click here for additional data file. 10 Aug 2021Dear Dr. Doering, Dear Reviewers,Thank you very much for allowing us to revise our submission and for the very helpful comments. We have carefully revised the manuscript accordingly.Sincerely,Juliane Burghardt________________________________________Reviewer #1: Summary and overall impressionThe present study investigated whether gender differences in the effectiveness of treatment of mental illness are evident in psychosomatic rehabilitation. Previous studies showed such an effect, although the evidence for this has been less clear in studies conducted in recent years. The present work shows that gender differences are partly present but clinically negligible. Differences are evident in very young and very old patients, although also small. The authors discuss different reasons why gender differences are less apparent compared with the past. The paper thus represents an important work in the field of psychosomatic rehabilitation, as it demonstrates that treatment is almost as effective for women as for men compared to the past. The sample size in all three age cohorts and the inclusion of measures of self-assessment and external assessment in the analysis are strengths of the study. Nonetheless, the fact that there are many more individuals in the middle age cohort would be important to address more in the discussion. This uneven distribution of age cohorts has a large impact on the overall lack of differences in the sample. As the authors themselves describe, it would also have been desirable if statements about gender role orientation had been possible, as these appear to be highly relevant to the interpretation of the results. Overall, the paper is very clear and well structured. It provides interpretative information on many relevant points and represents an important gain in knowledge concerning the effectiveness of psychosomatic rehabilitation.Specific improvementsMajor issues- The discussion should strongly consider that the middle age group contained significantly more individuals, which reduced the gender effects so much in the overall analysis, although there are at least small differences in the other two age groups. I would like to see a more nuanced discussion of this.++ We have added this to the discussion: “Since most patients in this study fall within the middle age group the very small overall gender effect is driven by this age group. However, previous meta-analyses of psychosomatic rehabilitation interventions show that this age distribution is representative of psychiatric rehabilitation clinics in Austria and psychosomatic rehabilitation clinics Germany .” (p. 12)Minor issues- Page 3 “Among other things, seeking help […]“: n my view, the sentence does not fit well as an explanation for the effects of gender role in rehabilitation, since the individuals have already sought help and started rehabilitation. Or are there findings that men then take the treatment itself less seriously or make less use of it during inpatient treatment?++ We agree and have clarified the explanation. “Among other things, seeking help and support contradicts the male gender role, which is why men often show less help seeking behavior than women [10] and communicate less effectively with health care providers. For instance, some men may understate pain or hide emotions [8] or are less accurate about their medical records [11]. The loss of autonomy during treatment is possibly more problematic for men than for women [12]. The patient role is incongruent with the male gender role [13], which is active and agentic. In line with the male gender role, men prefer a higher level of control over the therapeutic process and report a need for action-oriented problem-solving strategies [12].” (p. 3-4)- Page 4: “Women suffer more often […]“: This sentence seems in the wrong place, since it seems that it does not contribute to the linked arguments in the sentences before and after this sentence.++ We have deleted the sentence.- Page 6: I would recommend to put the G*Power analysis together with a more detailed description of the conducted analyses in the Analyses section. Especially the repeated-measure ANOVAs could be described more in detail.++ We have restructured the method section and included the power analysis in the analysis section.- Page 9: “The biggest effects were found in for functional ability […]”++ We have corrected that.- Page 10: “[…] men showed the better course in this measure, which might be because […]”: Since the second half of this sentence is an interpretation, it should be moved to the discussion.++ We have removed the interpretation from the result section.- Page 24: Table 2 needs some revision in the section “Employment”. The percentage of employed people in the oldest WHO group is in the wrong line and is missing it’s percent sign.++ We have revised the Table.- The authors should point out in the limitations, that the data was obtained only from one clinic and therefore generalization is limited. Furthermore, they should discuss that the data of some patients is ten years old and gathered over a long period of time, where e.g. changes in the understanding of gender roles in the society could have changed slightly and therefore confounded the analyses.++ We have revised the limitation accordingly.“Additionally, the data was collected between 2011 and 2015. It is thus, plausible that new changes have occurred. This and the fact that the data was only gathered in one clinic makes it necessary to replicate our findings.” (p. 13)________________________________________Reviewer #2: This is an interesting paper about the effects of gender on the treatment outcomes of inpatient psychiatric rehabilitation in Austria. The paper is fairly clear in the approach and analysis. The manuscript would benefit from a few changes for readability and clarity.Introduction*Please describe psychosomatic rehabilitation- how is this the same or different from psychiatric rehabilitation? It may be helpful to use either one term or the other- the term “psychiatric” is preferred to describe hospital treatment.++ We have added explanations for the similarities and differences between psychosomatic and psychiatric rehabilitation interventions. In fact, what is called psychosomatic rehabilitation in Germany is very similar to what is called psychiatric rehabilitation in Austria. However, since these terminological differences are somewhat political in Austria, we would prefer to use both terms.Both psychosomatic and psychiatric rehabilitation involve inpatient hospital treatments. “Psychosomatic rehabilitation in Germany and psychiatric rehabilitation in Austria are very similar approaches to treat mental disorders. Both emphasize psychotherapeutic interventions, but also include psychopharmacological and various other complementary interventions, for instance excise and physical therapy. Both mainly treat patients with depressive or anxiety-related disorders.” (p. 8)* Please use rehabilitation interventions not rehabilitations++ Thanks, we did.p.4 Consider mentioning the subjective nature diagnosis – are there studies that examine the effect of clinician gender on treatment outcomes?++ In inpatient treatment it difficult to identify the clinician’s gender because patients are treated by multiple health care providers . Previous findings suggested that patient therapeutic dyads with the same gender could be more effective, however, since inpatients are treated by multiple individuals it seems difficult to generalize these results to inpatients. The diagnosis is merely included to help describe the sample.Method*There is some duplication in description of study design.++ We revised the method section to be less repetitive.*Please address why the BriefSCL and SCLwere both utilized and the comparability of results between them.++ We added information regarding the comparability of the two questionnaires. It’s unclear why the measures were changed, maybe for length. The persons likely responsible for this decision are not available. “The BSCL had been derived from the SCL-90 by selecting the items with the highest item loading. Previous data showed that the BSCL and SCL-90 are highly correlated . Both instruments provide a Global Severity Index (GSI), which is a commonly used measure of general psychological distress.” (p. 7)*It would be helpful for the reader to explain the “Hogrefe” system++ We have added information about the Hogrefe system. “The self-report measures were assessed using the Hogrefe test system. This system provides a platform that administers standardized questionnaires licensed by Hogrefe. It provides a user-friendly surface and assures data integrity.” (p. 7)Discussion*How are differences in symptom distress related to diagnosis? Is there an interaction effect of diagnosis and QoL?++ That is a very important question. However, we believe that an analysis of the relations between symptom distress and diagnosis and QoL would be too complex to add to this manuscript. The diagnosis should just help to describe the sample.*It may be helpful to also consider measurement error for current or previous research findings. Is there gender bias in the standardized tools?++ We have added a discussion of a gender bias within the measurement tool. “Previous work has noted that the gender differences could be partly attributed to biases within measures [18]. Since men and women often report different symptoms questionnaires can be biased towards capturing traditionally ‘feminine’ symptoms of a disorder. Therefore, it is notable that our study used the SCL-90 lists, which is the most common instrument used in studies within the MESTA-meta-analysis, which did find a gender effect β = .22 [3]. It is therefore unlikely that our results hinge on measurement biases.” (p. 12-13)*The statement “The present findings confirm that gender-sensitive treatment is possible, even if women are still more distressed than men upon admission.” Is not well supported by your research question or results. Rather, it seems to suggest that rehabilitation interventions are effective despite limited access to gender-sensitive treatment. It may also suggest looking at measurement tools differently to capture gender differences and/or the use of qualitative exploration to reveal gender differences.++ We agree, we have corrected the sentence to be more precise. “The present findings confirm that rehabilitation interventions can be equally effective among men and women, even though women remain more distressed upon admission than men. Thus, the higher symptom burden of women at admission does not necessarily lead to a difference in treatment effectiveness. It remains unclear whether the decline in gender differences on treatment effectiveness was caused by changes in society as a whole or by specific characteristics of the present treatment.” (p. 14)* There is also evidence that people in the age cohorts of younger and older adulthood may require age-specific treatment or gender-sensitive treatment based upon age. ++ We have added this to the discussion.“If the finding of comparatively bigger gender effects among older or younger patients replicates, this might imply a need for gender and age-sensitive treatments instead of a gender-sensitive treatment that ignores age.” (p. 14) 19 Aug 2021Gender effects on outcomes of psychosomatic rehabilitation are reducedPONE-D-20-37367R1Dear Dr. Burghardt,We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at onepress@plos.org.If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact Kind regards,Stephan Doering, M.D.Academic EditorPLOS ONE 20 Aug 2021PONE-D-20-37367R1 Gender effects on outcomes of psychosomatic rehabilitation are reduced Dear Dr. Burghardt:I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. onepress@plos.org.If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact plosone@plos.org. If we can help with anything else, please email us at Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staffon behalf ofProfessor Stephan Doering Academic EditorPLOS ONE


Serious games are a promising approach to improve gait rehabilitation for people with gait disorders. Combined with wearable augmented reality headset, serious games for gait rehabilitation in a clinical setting can be envisaged, allowing to evolve in a real environment and provide fun and feedback to enhance patient’s motivation. This requires a method to obtain accurate information on the spatiotemporal gait parameters of the playing patient. To this end, we propose a new algorithm called HoloStep that computes spatiotemporal gait parameters using only the head pose provided by an augmented reality headset (Hololens). It is based on the detection of peaks associated to initial contact event, and uses a combination of locking distance, locking time, peak amplitude detection with custom thresholds for children with CP. The performance of HoloStep was compared during a walking session at comfortable speed to Zeni’s reference algorithm, which is based on kinematics and a full 3D motion capture system. Our study included 62 children with cerebral palsy (CP), classified according to Gross Motor Function Classification System (GMFCS) between levels I and III, and 13 healthy participants (HP). Metrics such as sensitivity, specificity, accuracy and precision for step detection with HoloStep were above 96%. The Intra-Class Coefficient between steps length calculated with HoloStep and the reference was 0.92 (GMFCS I), 0.86 (GMFCS II/III) and 0.78 (HP). HoloStep demonstrated good performance when applied to a wide range of gait patterns, including children with CP using walking aids. Findings provide important insights for future gait intervention using augmented reality games for children with CP. Cerebral Palsy (CP) is the most common cause of childhood disability, affecting 17 million people worldwide . CP descTo reverse this trend, physiotherapists propose overground or treadmill-based gait training, with varying body weight support . FunctioThe application of technology in the field of rehabilitation is becoming increasingly popular. Within the range of choices available to therapists and patients, virtual/augmented reality (VR/AR) systems are feasible, effective and have positive effect on compliance with therapy and motivation of the patient ,12. ThesThanks to the miniaturization of the devices and the commercial development of affordable products, wearable technology-assisted devices appear to be an interesting tool for gait rehabilitation in overground condition  ,19,20,21Today, there is no AR system or serious game designed for overground gait training, including a rigorous protocol based on the patient’s walking performance and abilities. One of the essential components of such a system is the real-time tracking of the spatio-temporal gait parameters in people with gait disorders. Several methods exist that use full kinematic captures ,23,24 orMultiple methods exist for calculating spatiotemporal gait parameters, whether based on force plates or reflective marker systems ,23,24. HWearable sensors based on inertial measurement units (IMUs) or accelerometers have been validated in both normal and pathologic gait to detect gait events both in controlled laboratory conditions ,26,27,28In a study including people with gait disorders, two magneto-inertial units including a tri-axial accelerometer, a tri-axial gyroscope and a tri-axial magnetometer (MIMUs) were fixed to the malleoli for the determination of both temporal and spatial parameters . The gai®  worn on the trunk. They showed a very good sensitivity, specificity and precision for detection of locomotion period: between 86% to 97%. But, they highlighted that for short period of locomotion and/or if the gait pattern is unsteady with high variability, the error can be important [In children with CP-GMFCS I-II , some previous studies have demonstrated acceptable validity of accelerometry to detect mobility-related metrics, such as the total number of steps per day, walking distance ,34,35, amportant . Moreovemportant .Globally, results indicate that adaptive and custom algorithm is suitable for calculating spatio-temporal gait parameters in people with gait disorders. But these techniques, despite their great robustness, have potential drawbacks for coupling them with AR/VR systems in clinical context. The need for multiple devices to maximize accuracy, the difficulty in synchronizing with AR/VR systems and the complexity of the user’s equipment mean that the system is not “plug and play”. A simpler configuration, with a single device, could allow for wider clinical application.To our knowledge, there are very few studies using an AR HMD (Hololens) for calculating spatio-temporal gait parameters. As a preliminary study, Guinet et al. showed that the accuracy of the Hololens was sufficiently high to evaluate the position of the user’s head, without spatial drift, in comparison to MOCAP system. They found an absolute errors between 55 to 250 mm in all 3 planes . Using tThirteen healthy adults and sixty-two children with CP were included. Healthy adults had to be 18 years or older and normal or corrected vision. Subjects were recruited at the Poidatz Rehabilitation Center adjacent to the gait lab. The inclusion criteria for people with CP were an age between 10–18 years, a Gross Motor Function Classification System (GMFCS)  I to IIIThe gait laboratory used a fifteen-camera VICON system  . Data were collected from markers placed on the headband (4), pelvic (4) and feet (6). Data were recorded at 100 Hz and filtered using a real-time 2nd order low-pass Butterworth filter (with a cutoff frequency of 6). VICON system was considered as a reference for gait analysis and spatiotemporal gait parameters calculation. Hereafter in this article, VICON system has been called MOCAP.The HoloStep algorithm has been written in C# language. It was a part of the AR application developed with Unity 2019.2.8f1 (64-bit) using Mixed Reality Toolkit version 2 for Microsoft Hololens HMD. This version of AR application did not contain any hologram in order to be comparable to MOCAP. Data were recorded at 100 Hz and filtered using a real-time 2nd order low-pass Butterworth filter (with a cutoff frequency of 6). This application has been deployed in Microsoft Hololens version 1 . In the X-axis points right, the positive Y-axis points up  and the positive Z-axis points towards you , Step length (m) and Walking distance from the beginning of the trial (m). These data are stored in memory for direct use in the AR application, and logged in a The data acquisition rate was 100 Hz. At each frame, HoloStep calculates: Time (s), Position , the body was at a lower position on y-axis. Therefore, when the user was leaning to the left (x min) and the body was at a lower position (y min), the left foot of the user started to touch the ground. The similar situation happened on the other side (x max and y min).Each gait cycle was divided into two phases: stance and swing. Stance consisted of the entire time that a foot was on the ground, starting with an initial contact (IC) when the foot touched the ground, and ending with a toe off (TO) when the foot left the ground. Swing corresponded of the entire time that a foot was in the air, starting with TO and ending at the next IC. The principle of detection used by HoloStep was based on the fact that during walking, the body displacement is pseudo-periodic. The body slightly leaned to the left/right side. It created a characteristic variation on locking distance was defined: new IC was considered only if the distance between two IC was greater than this threshold  was the dot product between walking direction  IC1IC2→ :IC1IC2→·Finally, the total walking distance was the sum of the successive step lengths.Participants were instructed to walk at a comfortable speed in a straight line along an 8-m path in the gait lab. Data were collected for three successful trials.Reference: Zeni algorithm using a set of pelvic and feet markers calculating spatiotemporal gait parameters with high accuracy ;Challenger: HoloStep algorithm using head pose.The user’s head position was measured with the AR HMD and with MOCAP using 4 reflective markers placed on the AR HMD. Pelvic and feet position were measured with MOCAP using reflective markers. Dataset was processed using two different algorithms:R and translations T) [H and G. The aim was to find for each point p in H its closest point in G. The second step was to apply a transformation (R and T) in order to minimize the distance between the correspondence pairs:From HoloStep algorithm (C#) deployed in the AR HMD, user’s position (tions T) ,45. The r and determination coefficient Bland and Altman analysis was performed to compare walking speed, step length and cadence between the two methods given the bias CC) . The PeaThe two-sample t-test was done to compare means of the two methods for walking speed, step length and cadence. The 5% significance level was used to reject the null hypothesis. The confusion matrix allowed visualization of the performance of HoloStep algorithm: sensitivity (true positive rate), specificity (true negative rate), accuracy (true negative and positive rate) and precision  of step detection for HoloStep algorithm, for each group, were calculated. Each row of the matrix represented the instances in the challenger class (HoloStep), while each column represented the instances in the reference class (Zeni).For the 13 healthy participants, the total number of IC detected was 65 with Zeni and 63 with HoloStep. The HoloStep algorithm ignored 2 IC  for 2 participants. Sensitivity, specificity, accuracy and precision of HoloStep algorithm were excellent . The Blas 5.6 cm .For the 32 participants from group 1 , the total number of IC detected was 194 with Zeni and 195 with HoloStep. The HoloStep algorithm ignored 6 IC  and added 7 false IC  for 7 different patients. Sensitivity, specificity, accuracy and precision of HoloStep algorithm were excellent . The Blang speed a. The meng speed a. The ICng speed .For the 30 participants from group 2 , the total number of IC detected was 184 with Zeni and 185 with HoloStep. The HoloStep algorithm ignored 2 IC  and added 3 false IC  for 3 different patients. Sensitivity, specificity, accuracy and precision of HoloStep algorithm were excellent . The Blang speed b. The meng speed b. The ICng speed .This study is the first to describe and assess the validity of a custom algorithm deployed in the Hololens AR HMD to calculate spatiotemporal gait parameters both in healthy participants and children with CP. The results of our study suggest that HoloStep algorithm using Hololens AR HMD calculate spatiotemporal gait parameters with sufficient accuracy even in people with gait disorders using walking aids.HoloStep performance for speed calculation was comparable to those obtained with an IMU. For ex., Zijlstra et al. obtained a mean difference between predicted and real speeds below 0.05 m/s . HoloStep < 0.05). These between-systems biases were justified by the authors because of the drift in tracking and deviations in the map . Using data available in Recently, Geerse et al. proposed a method to calculate spatiotemporal gait parameters using a Hololens AR HMD and compared this method to the reference Interactive Walkway System (IWS). They found that ICC were excellent for between-systems agreement for walking speed, step length and cadence for healthy adults and people with Parkinson’s Disease (PD) (ICC > 0.92). But limits of agreement obtained with Bland-Altman analysis were quite narrow. Still, walking speed and step length were underestimated with biases increasing with faster walking speeds  . They alSun et al. have developed two AR-based automated functional mobility test using Hololens AR HMD: Sit To Stand (STS) and Time Up and Go (TUG). In comparison with reference inertial sensor , vertical kinematic data  shown a bias less than 0.02 s for STS and 0.13 s for TUG, with range of error within ±0.8 s. Correlation coefficient for kinematic measurement agreement between Hololens and reference sensors were from 0.74 to 0.99 . We obtaChildren with CP present alteration of dynamic stability during gait because of deficits in balance and postural control. Hsue et al. demonstrated that children with CP showed significantly larger vertical and medio-lateral displacements of the Center of Mass than TD group. But, the trajectories have the same shape  both for TD group than children with CP. In vertical directions, the Center of Mass reached a maximum peak at mid-stance, and a minimum at the end of terminal stance (when the two feet are in contact with the ground). It was interesting to observe that the minimum peaks were shifted for children with CP (4% of gait cycle after) . When chHoloStep is based on the kinematics of the head, which requires special attention as it has 6 degrees of freedom and can have variable patterns. In sagittal plane, the variability of head displacement for children with CP is high during gait . But, atWe have developed and evaluated a new algorithm called HoloStep to calculate spatiotemporal gait parameters using only the head pose provided by an augmented reality headset (Hololens). It is based on the detection of peaks associated to initial contact event, and used a combination of locking distance, locking time, peak amplitude detection with custom thresholds for children with CP. An experimental comparison with a reference algorithm based on full motion kinematics shown that HoloStep accurately detected foot contact, and calculated step length, total distance walked and gait speed both for children with CP and healthy participants.Once the gait parameters have been obtained, another step before designing relevant rehabilitation exercises is to investigate feedback on gait performance in AR. We therefore started to model and evaluate different visual feedback on speed, and their effects on patients’ walking performance. We have also started the development of a serious game using a process framework that involves a multidisciplinary team and is inspired by existing methodologies ,54. ThisBeyond this specific application, we believe that the HoloStep algorithm can be implemented in other serious games aimed at a wider range of different patients for motor rehabilitation purposes.


Tripartite motif 47 (TRIM47) belongs to a category of the TRIM family. It takes part in cancer tumorigenesis, thus demonstrating important functions across numerous carcinomas. Unfortunately, it is still elusive towards TRIM47 expression, characteristic, and biological function in brain gliomas. In vitro experiments were performed to validate TRIM47-mediated effects on glioma cell proliferation, migration, and invasion.  Public database analysis was applied to analyze TRIM47 expression, and quantitative real-time PCR (qRT-PCR) was applied to detect the expression of TRIM47 in 9 paired tissues of glioma. The Cancer Genome Atlas (TCGA) and the Chinese Glioma Genome Atlas (CGGA) databases were applied to evaluate the overall survival (OS). Gene Ontology (GO) term and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways were applied to analyze differentially expressed gene (DEG) functions.  Compared to that in normal tissues, TRIM47 expression was greatly higher in glioma tissues, and its expression level was associated with different grades of glioma. Our data indicated that highly expressed TRIM47 displayed an association with the poor prognosis of glioma patients. Ablating TRIM47 obviously impeded glioma cell invasion and migration.  TRIM47 could modulate glioma cell proliferation, invasion, and migration. Highly expressed TRIM47 exhibited a correlation with poor prognosis. All data imply that TRIM47 is a probable biomarker for glioma and has the potentiality to become a newly generated target for glioma treatment. Glioma is a widely occurred malignant neoplasm in the nervous system . It has Tripartite motif 47 (TRIM47) protein belongs to a category of the TRIM family and participates in many cellular processes, such as cell proliferation . TakayamIn our study, we attempted to systematically validate TRIM47 function in glioma. The TRIM47 level in glioma specimens was measured, and the relationship between TRIM47 and glioma was then studied utilizing several biological assays. Our findings collectively suggested that TRIM47 could be regarded as a modulator of glioma cell development.https://cistrome.shinyapps.io/timer/) and Gene Expression Profiling Interactive Analysis . The mRNA-seq and relevant clinical data of glioma patients were acquired from The Cancer Genome Atlas  and the Chinese Glioma Genome Atlas  database.The levels of TRIM47 in multiple cancers and normal tissues were reviewed using Tumor Immune Estimation Resource  term and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways were executed to analyze the enrichment of the DEGs. The enriched GO terms and KEGG pathway were identified by the cutoff criteria of “adjusted 2.HEB, SW1783 (HTB-13), U373 (HTB-17), SW1088 (HTB-12), U87 (HTB-14), and A172 (CRL-1620) were from the American Type Culture Collection . They got maintained in DMEM with 10% FBS  at 37°C with 5% COΔΔCt- method was applied to tackle all the data. TRIM47 primers and GAPDH were synthesized by Sangon Biotech Co., Ltd. . Primer sequences were as follows: TRIM47, forward, 5′-CTGAGCAGTCCAAAGTCCTGA-3′; reverse, 5′-CTACGGCTGCACTCTTGATG-3′; GAPDH, forward, 5′-GGAGCGAGATCCCTCCAAAAT-3′, reverse, 5′-GGCTGTTGTCATACTTCTCATGG-3′.Whole RNA was harvested by TRIzol reagent . Complementary DNA (cDNA) was produced by the PrimeScript RT Kit . QRT-PCR was conducted using SYBR premix Ex Taq I. GAPDH was selected as a reference. The 2Shanghai Gene Pharmaceutical Co., Ltd.  synthesized TRIM47 short interfering ribonucleic acid (siRNAs). si-TRIM47 and si-NC were transfected into cells by lipofectamine 2000 reagent . The sequences were as follows: si-TRIM47 #1, 5′-CCTCAAGTTTGCCTATATT-3′; si-TRIM47 #2, 5′-GCAGCTGTTTGGAACCAAA-3′; si-NC, 5′-UUCUCCGAACGUGUCACGUTT-3′.3 cells/well were inoculated in a 96-well plate, and 10 μL of CCK-8 solution/well was supplemented at a certain time. All cells were incubated for 2 hours at 37°C incubators. The OD value of 450 nm was observed on a microplate reader . All the data were derived from three separate experiments in triplicate.Cell Counting Kit- (CCK-) 8 Assay  was applied to detect cell proliferation. 5 × 10μm; Costar Corporation, USA) in the presence or absence of matrigel . The upper insert contained 1 × 105 cells. The lower chamber included 700 μL of medium with 20% FBS and was used as a chemical attractant. After 24 to 48 hours postculture, cells remaining in the lower chamber were fixed with ethanol, followed by stain using 0.2% crystal violet.Transwell analysis was conducted using Transwell chambers  objective. This toolset was a sort of database responsible for integrating the data of gene expression and clinical information and could be applied to analyze the prognostic value of TRIM47 in glioma.The correlation between TRIM47 and glioma prognosis was assessed by the Kaplan-Meier plotter tool  ratio was interpreted by Kaplan-Meier. Cox proportional hazard model multivariate analysis was used to determine the TRIM47 level and clinicopathological features on OS. P < 0.05 with a 95% of confidence interval means an obvious difference in two or more groups.All the data were obtained from three separate experiments in triplicate one time. SPSS 17.0 software  was executed to analyze the statistics. The comparison existing in different groups was analyzed by Student's GEPIA and TIMER datasets were applied to analyze the differential levels of TRIM47 in various tumor and adjacent normal tissues. The results revealed that TRIM47 was an oncogene in most tumors like cholangiocarcinoma (CHOL), esophageal carcinoma (ESCA), liver hepatocellular carcinoma (LIHC), and lung adenocarcinoma (LUAD), but it was a tumor-suppressor gene in kidney chromophobe (KICH) and prostate adenocarcinoma (PRAD). Of interest, our data suggested that the level of TRIM47 was largely raised in glioblastoma multiforme (GBM) and lower-grade glioma (LGG) tissues after GEPIA database analysis . NeverthP < 0.001). Heightened TRIM47 expression levels were accompanied by the increase of glioma WHO grade in the CGGA database. Additionally, after analysis of the TCGA database, the TRIM47 expression level in LGG and GBM was also significantly upregulated compared with that in normal tissues. More importantly, TRIM47 expression levels were also higher in GBM than LGG , including axonemal dynein complex, axoneme and inner dynein arm assembly, cellular response to fibroblast growth factor stimulus, inositol phosphate metabolic process, fibroblast growth factor receptor signaling pathway, assembly, miotic cell cycle phase transition, positive modulation of protein localization to chromosome telomeric region, and modulation of a p53-mediated intrinsic apoptotic signaling pathway . KEGG paTRIM47 expressions were determined in glioma tissues and cell lines. In view of the above assays, we silenced TRIM47 in SW1783 cells by si-TRIM47 #2 to detect the impacts on cell proliferation. Our data suggested that the reduction of TRIM47 greatly hindered cell proliferation, especially in SW1783 . SW1783 Gliomas are the widely occurred malignant brain neoplasm , 12. AmiTRIM is overexpressed in several tumors . NeverthThe functions of molecules in an individual usually fulfill through interactions with others not alone only . DiffereFinally, we performed the CCK-8 assay and Transwell assay to detect TRIM47 function in glioma. After knocking down TRIM47, we found that glioma cell proliferation, migration, and invasion were inhibited.This study has limitations. The number of clinical samples is not large enough. In future studies, we will collect more clinical samples and clinical parameters of glioma patients, including age, gender, and survival time, to further explore the function of TRIM47 in glioma. In addition, the regulatory mechanism involved in TRIM47 in gliomas will be further studied.To sum up, this study explored the role of TRIM47 in glioma for the first time. Based on public databases, we analyzed the expression level of TRIM47 in human tumors. The results showed that TRIM47 was significantly overexpressed in glioma, and the expression level of TRIM47 was positively correlated with the WHO grades of glioma. The high expression of TRIM47 had a significant correlation with the shorter OS of patients with glioma. These findings demonstrated that TRIM47 expressed highly in the glioma cells. Highly expressed TRIM47 could promote glioma cell proliferation, migration, and invasion. Our results provide a better understanding of the role in glioma. All data collectively indicate that TRIM47 is a prospective biomarker of glioma.


Cow’s milk allergy (CMA) is the most common food allergy in early childhood, and its prevalence continues to rise. Exclusive breastfeeding is recommended for infants in the first 6 months of life, but this recommendation is poorly adhered to in many parts of the world, including the Middle East, North Africa, and Pakistan (MENAP) region. If the infant is affected by CMA, current guidelines recommend extensively hydrolyzed formulas (eHFs) or amino acid-based formulas (AAFs) in the case of severe symptoms, and hydrolyzed rice formulas (HRFs) where available. In recent years, HRFs have been proposed as a plant-based alternative to cow’s milk protein-based eHFs, and updates to current guidelines have been recommended. In 2014, a consensus statement and guidelines were published for the Middle East region on the prevention, diagnosis, and management of CMA. As new advances have been made in the extensively hydrolyzed hypoallergenic infant formula space, along with updated scientific evidence, a workshop of experts from the MENAP region focused on HRF was convened in 2021. This publication summarizes the insights from this meeting. During the consensus part of the meeting, a new approach was discussed and approved by all participants, and agreement was reached that HRF can be recommended as a first-line alternative to cow’s milk-based eHF in the dietary management of CMA. Allergy risk has become a significant public health issue with rising prevalence, and despite past, current, and ongoing research, the reasons are not fully understood ,2,3. In Cow’s milk allergy (CMA) is the most common food allergy in early childhood, and approximately 80% of children will outgrow it by 3–5 years of age ,5; its pAs new advances have been made in extensively hydrolyzed hypoallergenic infant formulae, along with updated scientific evidence, a workshop of experts from the MENAP region focused on HRF was convened in 2021. This publication summarizes the presentations, discussions, and findings from this meeting, discussing the advantages of HRF in the dietary management of infants with CMA. During the consensus section of the meeting, a potential new approach to the therapeutic management of CMA using HRF was discussed and approved by all participants.On Friday, 9 April 2021, a virtual roundtable was held for HCPs from the MENAP region . Representative countries included Egypt, Kuwait, Saudi Arabia, and the United Arab Emirates. The meeting was chaired by Yvan Vandenplas, Head of the Department of Paediatrics, “KidZ Health Castle”, at the University Hospital Brussels in Belgium. The primary goal was to align on challenges with currently prescribed first-line formulas for CMA dietary management and as part of a diagnostic elimination diet .Box 1Align on challenges with formulas currently prescribed first line for CMA dietary management and as part of a diagnostic elimination diet, leveraging findings from a recent MENAP HCP survey.Define the evidence-based benefits of HRF compared with cow’s milk protein-based eHF.Highlight the drawbacks and limitations of pHF-W and why its use should be limited in the prevention of CMA.Align on a set of recommendations HCPs can use to determine when and where to initiate HRF.Legend: CMA, cow’s milk allergy; eHF, extensively hydrolyzed formula; HCP, healthcare professional; HRF, hydrolyzed rice formula; pHF-W, partially hydrolyzed whey formula.This roundtable built on a previous event hosted in August 2020 with some of the same participants, which focused on introducing HRF in general and raising awareness for its evidence-based benefits as a plant-based alternative to cow’s milk protein-based eHF.The workshop was divided into three sections: the presentation and discussion of HCP survey findings from the MENAP region, an expert presentation from Christophe Dupont , and a facilitated discussion on consensus statements on the use of HRF by HCPs in the MENAP region.A brief survey of six questions was distributed to 50 HCPs  with an interest in infant nutrition and cow’s milk allergy in Kuwait, Saudi Arabia, and the United Arab Emirates in advance of the roundtable, to assess current first- and second-line approaches to the dietary management of CMA. Responses  were collected between 11 February and 25 March 2021. Key findings are presented in Access to and the availability of HRF remains the biggest barrier to its widespread usage by physicians in the MENAP region. Additionally, the fact that one third of HCPs surveyed are prescribing pHF-W to their patients despite current guideline recommendations may illustrate that a lack of understanding exists on the difference in hydrolysis between pHF-W and eHF, and also that HRF category-specific education is needed in this region, starting at the first-line prescriber level. The MENAP expert attendees described affordability, palatability, and clinical response as the most important criteria to them when considering switching to a different formula.Christophe Dupont presented his clinical experience with HRF from a gastroenterologist’s perspective. He briefly overviewed HRF, the rationale for its first- and second-line use, and introduced three clinical case studies. The attendees discussed whether HRF could be used first line and debated the inclusion of HRF in an elimination diet as part of the CMA diagnostic work-up. They discussed the lack of market availability of HRF in the MENAP region. It is not a quick process to change HCP prescribing behavior, as evidenced by the length of time it has taken for HRF to become mainstream practice in some European countries. Indeed, HRF is currently marketed mainly in Italy, France, and Spain .For the development of a regional consensus on the use of HRF for CMA in the MENAP region, a structured quantitative method was used to facilitate the discussion and reach a consensus . StatemeUltimately, there was strong belief among MENAP experts in the evidence-based benefits of HRF based on full consensus on nearly all statements presented . An exceLocal clinical data/experience will be essential to increase physician confidence in regions where HRF is not currently an option , as will endorsement through potential third parties, as that level of credibility resonates with this audience. It will be critical to raise awareness and disseminate knowledge among a variety of HCPs via scientific meetings, presentations, and community webinars, and to concisely communicate the evidence-based benefits of HRF in an easy to digest format . Local-level efforts will be important education avenues once COVID-19 restrictions ease to increase confidence and help change recommending behavior in the MENAP region among all levels of HCPs—from first-line prescribers to specialist pediatricians.A summary of key findings from this workshop is reported below . This roBox 2Many HCPs surveyed in the MENAP region prescribe pHF-W to their patients despite local guideline recommendations, illustrating that HCPs may not be properly confirming a CMA diagnosis before making a formula recommendation.Compared with eHF, HRF has better palatability and is free from residual cow’s milk protein.Access and availability are still seen as the biggest barriers to widespread usage in the region.For regions where HRF is not currently available as a treatment option for CMA , local clinical data, real-world case studies, and practical experience will be essential to increase physician confidence in recommending HRF.Third-party credibility resonates with this audience, as the questions asked of Dr. Vandenplas and Dr. Dupont illustrated a desire to learn more about HRF and their clinical experience.Given that the previous Middle East consensus statements do not mention HRF (Vandenplas 2014), these new consensus statements will be a crucial first step in helping to drive clinical practice change once HRF is readily available.There was consensus on nearly every single statement presented (except a minor edit to statement 11). This shows that there is a strong belief in the evidence-based benefits of HRF and that once availability and education intersect, there is tremendous potential for HRF to be used first line as a CMA dietary management option.Once HRF becomes more readily available in the MENAP region and first-line prescribers become more familiar with its benefits, there is potential for HRF uptake as a first-line CMA dietary management option.Legend: eHF, extensively hydrolyzed formula; CMA, cow’s milk allergy; GI, gastrointestinal; HCP, healthcare professional; HRF, hydrolyzed rice formula; MENAP, Middle East, North Africa, and Pakistan; pHF-W, partially hydrolyzed whey formula.


Deep evolutionary origin of gamete-directed zygote activation by KNOX/BELL transcription factors in green plants. Published 28 September 2021BELL family gene in sporophyte and spore formation in the moss Physcomitrium patens. Two more publications suggesting roles of Physcomitium BELL genes in sporophyte development and egg size regulation have been cited, but not highlighted well in our publication. We apologize for the lack of proper citation of the previous works.We overlooked an important publication by Ortiz-Ramírez et al. (2017) implicating a role of a The new citation:Nature 549: 91–95. DOI: 10.1038/nature23478, PMID: 28737761Ortiz-Ramírez, C., Michard, E., Simon, A. A., Damineli, D. S. C., Hernández-Coronado, M., Becker, J. D. & Feijó, J. A. 2017. GLUTAMATE RECEPTOR-LIKE channels are essential for chemotaxis and reproduction in mosses. #1 (Abstract)Original text:Physcomitrium patens and Arabidopsis thaliana, KNOX and BELL proteins function in meristem maintenance and organogenesis during the later stages of diploid development.By contrast, in land plants such as Corrected text:Physcomitrium patens and Arabidopsis thaliana, KNOX and BELL proteins function in sporophyte and spore formation, meristem maintenance and organogenesis during the later stages of diploid development.By contrast, in land plants such as #2 (Discussion)Original text:M. polymorpha and C. reinhardtii, this finding is somewhat unexpected from a phylogenetic viewpoint because KNOX/BELL proteins in the model bryophyte P. patens control sporophyte development, as do KNOX/BELL proteins in angiosperms.While our study revealed the striking conservation of KNOX/BELL functions between Corrected text:M. polymorpha and C. reinhardtii, this finding is somewhat unexpected from a phylogenetic viewpoint because KNOX/BELL proteins in the model bryophyte P. patens control sporophyte development, as do KNOX/BELL proteins in angiosperms, as well as egg size .While our study revealed the striking conservation of KNOX/BELL functions between #3 BELL gene in P. patens eggs, reported by Horst et al., 2016, was not reflected in Figure. 7B. The corrected Figure 7B is shown now.In the published article, expression of a The corrected Figure 7B is shown here:The originally published Figure 7B is also shown for reference:


Staph. epidermidis, No. 605, exhibited the highest activity compared to others, degrading available histamine to 58.33% within 24 h. By polymerase chain reaction (PCR) analysis, the isolate, No. 605 that exhibited remarkable histamine‐degrading activity lacked the genes encoding coagulase and DNase, nor did it harbor any of the five classical enterotoxin genes. This is the first report to show that seven Staphylococcus species, including Staph. chromogenes, Staph. aureus, Staph. haemolyticus, Staph. epidermidis, Staph. pseudintermedius, Staph. agnetis, and Staph. hyicus, were able to degrade histamine, which were hitherto not known to have this capacity. Therefore, histamine‐degrading activity is a definite criterion to introduce fermenting organisms able to decrease histamine content in different food products.Histamine is an active amine compound that occurs in various fermented foods that may cause adverse effects on the human health. Certain microorganisms are able to degrade histamine by an oxidative deamination reaction. Therefore, the present study aimed to quantify histamine‐forming and/or ‐degrading activity of the isolates derived from milk of goat and sheep herds, in Iran, by the capillary zone electrophoresis (CZE) method; and we evaluated the molecular characteristics of staphylococcal isolates. Among 243 staphylococcal isolates, 29 histamine‐degrading bacteria were identified. One of these isolates, identified as  Staph. epidermidis, No. 605, exhibited the highest activity compared to others, degrading available histamine to 58.33% within 24 h. By PCR analysis, the isolate, No. 605 that exhibited remarkable histamine‐degrading activity lacked the genes encoding coagulase and DNase, nor did it harbor any of the five classical enterotoxin genes.Among 243 staphylococcal isolates, 29 histamine‐degrading bacteria were identified. One of these isolates, identified as  All the farms practiced manual milking. Discarding first streams of milk, 25 ml from both cleaned and disinfected teats was collected in a sterile tube and samples were immediately transferred on ice. Following, samples (10 μl of each) were subcultured on Baird–Parker agar and passed 48 h of incubating at 37°C. Morphological characteristics, gram staining, and catalase and oxidase tests were applied for colony screening. Regarding mentioned properties, colonies representing genus 2.2The primers used for the identification of staphylococcal strains, Tstag765 and TstaG422, were designed as previously reported , washed once with phosphate buffer , and inoculated in 5 ml of sodium phosphate buffer supplemented with histamine (1 mM). The suspension was then incubated at 37°C for 24 h. Histamine‐supplemented medium without bacterial culture was used as negative control, while Staph. xylosus PTCC 1444  functioned as positive control  at 4°C and the supernatant was filtered with 0.45‐μm filter paper  were washed once with phosphate buffer , pelleted by centrifugation , and inoculated in 5 ml of sodium phosphate buffer supplemented with histidine (0.5 mM) for 24 h incubation at 37°C. Five ml of histidine‐supplemented phosphate buffer (0.5 mM) with no bacterial culture and one incubated with Staph. epidermidis TYH1, histamine‐forming strain isolated from fish‐miso in Japan  at 4°C and filtered through a 0.45‐μm filter , thermostable nuclease (nuc), and staphylococcal enterotoxin (SE)  genes.Molecular characteristics of the isolates obtained in the present study were performed by identification of genus and detecting coagulase  with modification, based on manufacturer's instructions.2.6.2Table 2.6.32; Ampliqon). The amplification was carried out in a gradient automated thermalcycler with a hot bonnet (Bioer XP Cycler) and analyzed by 1.4% agarose gel electrophoresis in TAE (1×).All the uniplex PCRs employed in the present study were set up in a final volume of 25 μl, containing 50–100 ng genomic DNA, 0.1 µM of the respective primer and 12.5 μl of Taq DNA polymerase 2.0× Master Mix RED   and Staph. aureus DSM 19,041 , were used as enterotoxin producers .All the experiments were carried out in triplicate and the results were expressed as mean values and standard deviations. Data analyses were performed using SPSS software Version 16.0 for Windows. The mean comparison was performed using the Duncan's Multiple Range Test (DMRT) at 3Tstag gene resulted in a single 370 bp product in 243 of the screened isolates.Based on biochemical and morphological characteristics, we differentiated colonies that represented staphylococcal isolates. With the help of Baird–Parker selective medium, 500 staphylococcal colonies were differentiated. Typical jet black colonies were observed in all the samples screened on Baird–Parker agar plates, and a subset of them revealed colonies surrounded by a clear opaque zone or halo. All 500 isolates showed typical Gram‐positive staining, morphological characteristics of cocci in clusters, and were also positive for catalase and negative for oxidase activity. The PCR amplification of the y = 0.000004x (r2 = .999). As shown in Table Staph. epidermidis. The other isolates tested had a range of noticeable effects in degrading histamine. Our positive control, Staph. xylosus, degraded 17.70% of initiate histamine content, whereas the negative control exhibited no histamine degradation.For histamine‐degrading ability, we inoculated resting cells of these 243 different confirmed staphylococcal isolates in 5 ml of sodium phosphate buffer containing 1 mM histamine for 24 h, and Table Staph. chromogenes, eight (27.6%) to Staph. aureus, four (13.8%) to Staph. haemolyticus, four (13.8%) to Staph. epidermidis, one (3.4%) to Staph. pseudintermedius, one (3.4%) to Staph. agnetis, one (3.4%) to Staph. hyicus, and one (3.4%) to Staph. rostri. The most potent histamine‐degrading isolate detected was Staph. epidermidis (isolate No. 605). The observation that histamine‐degrading ability varied considerably across Staphylococcus of different species is consistent as per reports from several authors regarding diversity in this key phenotype. Monoamine oxidase and histamine degradation activities were observed by most of the Staph. xylosus strains tested in the study conducted by Martuscelli et al.  after an incubation time of 24 h. Zaman et al.  from milk of goats and sheep belonged to i et al. . The mosn et al.  demonstrStaph. haemolyticus, also possessing histidine decarboxylase activity. This isolate also degraded 29.16% of initiate histamine content in our assay. All amine oxidase‐positive strains showed simultaneous amino acid decarboxylase activity , including 8 Staph. aureus, 2 Staph. chromogenes, 2 Staph. epidermidis, 1 Staph. pseudintermedius, 1 Staph. hyicus, and 1 Staph. haemolyticus. Other isolates were PCR‐negative for the coa gene  for the amplification of a 270–300 bp specific band . SEs are commonly produced by coagulase‐positive Staphylococcus sp. but reports of detection of SE genes among coagulase‐negative Staphylococcus are also available. Currently, 23 different SEs are known but the 5 classical SEs especially SE type A (SEA) and SE type D (SED) are responsible for causing more than 95% of staphylococcal food poisoning cases  while the remaining 14 were coagulase‐positive (53.8%). Recently, Podkowik et al. ; Data curation ; Formal analysis (lead); Investigation (lead); Methodology ; Project administration (lead); Resources ; Software ; Writing – original draft (lead); Writing – review & editing (lead). Seyed Shahram Shekarforoush: Conceptualization ; Data curation ; Formal analysis ; Funding acquisition (lead); Investigation ; Methodology ; Project administration (lead); Software ; Supervision (lead); Validation (lead); Visualization (lead); Writing – original draft ; Writing – review & editing . Mahmoud Aminlari: Conceptualization ; Data curation ; Investigation (supporting); Methodology ; Project administration (supporting); Supervision ; Validation ; Visualization . Saeid Hosseinzadeh: Conceptualization (supporting); Data curation (supporting); Funding acquisition (supporting); Investigation (supporting); Methodology (supporting); Project administration (supporting); Supervision ; Validation ; Visualization (supporting). Victor Nizet: Conceptualization ; Data curation (supporting); Methodology (supporting); Project administration (supporting); Validation ; Writing – original draft (supporting). Samira Dahesh: Data curation (supporting); Software (supporting); Writing – original draft (supporting); Writing – review & editing (supporting). Samane Rahmdel: Conceptualization (supporting); Investigation (supporting); Methodology (supporting); Validation (supporting).


GJB2 gene encoding Connexin 26 (Cx26) which result in aberrant activation of connexin hemichannels. KID syndrome has no cure and is associated with bilateral hearing loss, blinding keratitis, palmoplantar keratoderma, ichthyosiform erythroderma and a high incidence of childhood mortality. Here, we have tested whether a topically applied hemichhanel inhibitor  could ameliorate the skin pathology associated with KID syndrome in a transgenic mouse model expressing the lethal Cx26-G45E mutation. We found that FFA blocked the hemichannel activity of Cx26-G45E in vitro, and substantially reduced epidermal pathology in vivo, compared to untreated, or vehicle treated control animals. FFA did not reduce the expression of mutant connexin hemichannel protein, and cessation of FFA treatment allowed disease progression to continue. These results suggested that aberrant hemichannel activity is a major driver of skin disease in KID syndrome, and that the inhibition of mutant hemichannel activity could provide an attractive target to develop novel therapeutic interventions to treat this incurable disease.Mutations in five different genes encoding connexin channels cause eleven clinically defined human skin diseases. Keratitis ichthyosis deafness (KID) syndrome is caused by point mutations in the  For example, mutations in five connexin genes have been linked to eleven genodermatoses, six of which result from mutations in connexin26 (Cx26)3. Keratitis ichthyosis deafness (KID) syndrome was linked to mutations in Cx26 in 20025. Increased activity of Cx26 hemichannels emerged as a common gain of function among the causative mutations12, and mouse models reproduced the epidermal pathology and displayed hemichannel activity in the affected keratinocytes14.Connexin mutations cause human genetic diseases affecting epithelial tissues16. Connexins form hemichannels in the ER-Golgi pathway18, and hemichannels are delivered to the plasma membrane, where they can become active channels, or dock with another hemichannel from an adjacent cell to form a gap junction channel19. Hemichannels allow the transmembrane flux of molecules, contributing to a wide range of physiological responses21.Connexins are subunits of gap junction channels, which allow passage of small molecules between adjacent cells22. Among KID patients, a genotype–phenotype correlation has emerged23. Patients with the Cx26-D50N mutation live into adulthood, and frequently develop squamous cell carcinomas25. In contrast, approximately 10% of KID patients die in early childhood, and two frequent mutations in this cohort, Cx26-G45E or Cx26-A88V, are always lethal22. For KID syndrome, hemichannel inhibition could have therapeutic value26. Flufenamic acid (FFA) is a non-specific connexin inhibitor that blocks hemichannels and gap junction channels28. FFA has previously been used in humans with side effects limited to gastrointestinal problems when used orally31. Commercially available topical creams containing FFA are used in humans for pain and inflammation associated with musculoskeletal and joint disorders and provide an ideal route of drug delivery for testing in mouse models of skin disease.KID syndrome is a dysregulated hemichannel disorder characterized by deafness, keratitis, palmoplantar keratoderma, and ichthyosiform erythroderma13. We found that FFA blocked the hemichannel activity of Cx26-G45E in vitro, and reduced epidermal pathology in vivo. FFA did not reduce connexin hemichannel expression, and cessation of treatment allowed disease progression.We examined whether topically applied FFA could ameliorate the skin disease associated with KID syndrome in a transgenic mice expressing the Cx26-G45E mutationXenopus oocytes injected with water showed negligible membrane current when depolarizing voltage steps were applied . Figure 13. Frozen sections showed an absence of EGFP fluorescence in control skin  in keratinocytes32. Figure Variation in epidermal pathology was observed between individual Cx26-G45E mice, most likely due to their outbred and undefined genetic backgroundTo test if topical treatment with FFA could ameliorate the skin disease associated with KID syndrome, we treated Cx26-G45E transgenic mice with topically applied FFA using commercially available Mobilisin cream . Xenopus laevis oocytes were purchased  and cultured in modified Barth’s (MB) medium10. Oocytes were injected with 10 ng of antisense oligonucleotide against Xenopus Cx3863, followed by Cx26-G45E mRNA (5 ng/cell). Antisense Cx38 oligonucleotide treated oocytes injected with water, instead of mRNA, served as controls.Human Cx26-G45E in pCS28. Current–voltage curves were obtained by clamping cells at − 40 mV and imposing voltage steps in 10 mV increments from − 30 to + 60 mV46.Hemichannel currents were recorded 24 h after mRNA injection using a GeneClamp 500 amplifier, Digidata 1440A, and pClamp software . Electrodes  were pulled to 1–2 MΩ resistance  and filled with 3 M KCl, 10 mM EGTA, and 10 mM HEPES, pH 7.4. Cells were recorded in MB medium without calcium26. FFA  was dissolved in DMSO at a concentration of 200 mM, and serially diluted into MB medium without calcium at concentrations between 1 and 500 µM. I–V curves were obtained before and after exchange of the extracellular medium with a known concentration of FFA. Percent inhibition was plotted against drug concentration and fit to a sigmoidal function  to determine the IC50.Extracellular solutions were exchanged using gravity perfusion32, no sex based differences were observed13. When fed a doxycycline containing diet , these mice express Cx26-G45E and enhanced green fluorescent protein (EGFP) as independent proteins in epidermal keratinocytes. Animals were genotyped by PCR amplification of tail genomic DNA  as described13.Animal work was approved by the Stony Brook University IACUC, and conducted according to the NIH Guide for the Care and Use of Laboratory Animals and in compliance with the ARRIVE guidelines. Male and female Cx26-G45E transgenic mice in the SKH1 outbred and uncharacterized genetic background were used2/sr/μW/cm2) for each animal subject.EGFP fluorescence was monitored in transgenic animals using an In Vivo Imaging System . Mice were anesthetized with isoflurane and whole body dorsal fluorescent images were acquired. EGFP fluorescence was recorded as the total radiant efficiency  and then treated topically with FFA, or vehicle, while still under isoflurane anesthesia following IVIS imaging. Mobilisin cream  containing 3% FFA (~ 110 mM) was purchased from an Italian pharmacy . FFA  was dissolved in DMSO at 200 mM, and mixed with Eucerin Cream  at a 1:5.7 ratio . For vehicle controls, DMSO was mixed with Eucerin Cream at the same 1:5.7 ratio. Mobilisin, FFA/Eucerin, or DMSO/Eucerin (~ 0.5 ml/ mouse) were applied to the dorsal epidermis. Mice were maintained under isoflurane anesthesia for 10 min in a warmed chamber to allow absorption of the cream. Statistical significance was determined using one way ANOVA, or the 2-tailed t-test (OriginLab Corp).13.Skin was fixed in 4% formaldehyde in PBS for 24 h at room temperature. Tissues were rinsed with PBS, dehydrated through an ethanol series, and embedded in paraffin. 2–3 µm sections were cut, deparaffinized, and stained with hematoxylin–eosinSkin was fixed in a 1% formaldehyde in PBS for 1 h at room temperature. Tissues were rinsed with PBS, immersed in Optimal Cutting Temperature compound , and frozen. 8–10 μm sections were cut on a cryotome, dried onto glass slides, and stained with polyclonal rabbit antibodies against Cx26 , washed with 0.1% Triton X-100/PBS, incubated with Cy3-conjugated anti-rabbit secondary antibodies , washed with 0.1% Triton X-100/PBS, and mounted using Vectashield with 4′,6-diamidino-2-phenylindole .


Rollators are widely used in clinical rehabilitation for gait assessment, but gait analysis usually requires a great deal of expertise and focus from medical staff. Smart rollators can capture gait parameters autonomously while avoiding complex setups. However, commercial smart rollators, as closed systems, can not be modified; plus, they are often expensive and not widely available. This work presents a low cost open-source modular rollator for monitorization of gait parameters and support. The whole system is based on commercial components and its software architecture runs over ROS2 to allow further customization and expansion. This paper describes the overall software and hardware architecture and, as an example of extended capabilities, modules for monitoring dynamic partial weight bearing and for estimation of spatiotemporal gait parameters of clinical interest. All presented tests are coherent from a clinical point of view and consistent with input data. Nowadays, a significant percentage of the population present some form of disability. Disability may have a major impact in autonomy, especially when it affects mobility. Motor rehabilitation is of key importance to recover walking capabilities. Depending on their condition, people often rely on mobility aids such as rollators or canes to complete their rehabilitation therapy. During therapy, patient evolution can be assessed via gait analysis. Traditionally, gait analysis is visually performed by clinicians, based on their expertise. This process has been formalized into scale-based clinical assessment, i.e., clinical experts visually evaluate patients while they perform a number of tasks and fill out a clinical scale, such as the Tinetti mobility test . Most scTechnology offers alternatives to manually compiled clinical scales. A typical approach consists of using force/pressure sensors on a walking surface such as a treadmill or a walkway ,3. OpticAlternatively, sensors can be attached to assistive devices rather than to specific environments or users themselves, so that monitorization is transparent to users and can be performed anywhere. Smart rollators are reportedly useful for monitorization purposes  as they A major problem with reported smart rollators is that most of them are ad hoc research prototypes, and commercial models are typically expensive. For example, the robotic rollator Guido had a large-scale commercial version with starting price over USD 6000 in 2004, which limited its success . BesidesThis work proposes a new smart rollator, Walk-IT  it is important from a clinical point of view ,25, and This paper is organized as follows. First, The gait cycle see  describeSingle support phases usually comprise more than 60% of the cycle . CliniciThere have been attempts at classification of gait abnormalities  based onCadence (CAD): Step time (SpT).m.Step length (SpL) Stride time (SdT).m.Stride length : Walking velocity (WV): Weight-bearing (WB): The authors already compiled most relevant studies to this respect in . SpecifiThere are many works on average values for healthy individuals , and alsStep time (SpT): Average time between maximum–minimum (right) or minimum–maximum (left) in seconds.Stride time (SdT): Average time between maximum–maximum (right) and minimum–minimum (left) in seconds.Number of Step (NoS): Numbers of inflection points.Cadence (CAD): Step length (SpL): Average length between maximum–minimum (right) or minimum–maximum (left) in seconds.Stride length (SdL): Average length between maximum–maximum (right) and minimum–minimum (left) in seconds.Distance(d): Distance walked by user in meters.Average walking velocity (WV): The authors also proposed in  a methodIn addition, user’s support , whereas the swinging limb moves forwards. Thus, the supporting limb can also be detected. We have added a 360As heel contact detection does not depend on weight-bearing on the platform, this new spatiotemporal detection algorithm solves the issues of the one in ; also, iWalk-IT modules have two design guidelines. First, they should be compatible with standard commercial rollators and based on low-cost commercial components, so building one or several platforms becomes feasible anywhere. In addition, the original rollator frame must be changed the least and its support and mobility properties must not be affected, as these devices are certified for medical use and any significant modification would require a new certification process.The Walk-IT in this work has been built over a Kmina Comfort Rollator  Figure , a standCommercial sensors  can be replaced by similar ones, and components of sensors specifically developed for Walk-IT  are also widely available and easy to purchase from different manufacturers. As a whole, depending on the cost of desired attached sensors, a basic Walk-IT can be built for less than EUR 350 . The following subsection describe each module in detail, as well as the ROS2 modules developed for basic control.Load sensors on the handlebars. Specifically, strain gauges are used in a Wheatstone bridge configuration to measure exerted support on each handle during the gait cycle. Gauges are adhered to the bars  and connThe Arduino board processes raw readings and makes them available through a serial-USB connection with a 2.5 Hz rate and a resolution of 5.5 gr. The whole circuit is protected with an adapted 3D-printed box attached to the bars. No modification of bar properties is performed, weight modification in the structure is minimal and symmetrical, and wiring is added to the brakes’ wiring harness. A basic Walk-IT includes one of these modules on each handlebar, to measure weight supported on each side of the rollator.Encoders on the wheels. User speed and step length are also required for gait analysis. Instead of modifying wheels in any way, encoders are attached to the rear wheels of the rollator, as shown in Basic gait parameters includes cadence, walking velocity, or stride time and length, which may change depending on the type of maneuver. Walk-IT can directly measure rollator position, speed, and applied forces. Other parameters need to be derived from these ones via processing. In order to obtain these basic parameters, every Walk-IT rollator must include the following modules (others can be added on a need basis):Both proposed modules are connected via USB to a Raspberry Pi, where the control system is running under ROS2. Even though Raspberry Pi offers other hardware buses  suitable for communication with Arduino boards, USB is favored to allow potential upgrade/replacement from Raspberry Pi to different embedded systems if necessary.Light detection and ranging sensor. A Light Detection and Ranging (LiDaR) has been attached under the lower-front transversal pole. This sensor has a twofold purpose: (i) to detect feet movement and gait phases, and (ii) to detect nearby obstacles and help with robot localization. In this work, an RPLidar A1M8 LiDaR from SLAMTEC was chosen. A1M8 is a low-cost LiDaR with 360 degrees field of view, 6-meter range, and an average scan rate of 5.5 Hz. Although it is required for leg support estimation, it is not strictly necessary for the basic configuration of Walk-IT.Although the basic Walk-IT configuration already provides several gait parameters, to show how it can be modularly extended, an additional commercial sensor has been included in this work:It can be noted that, since Walk-IT runs on ROS2, new commercial sensors can be added directly to the architecture, while ad hoc sensors  are simple to develop as well, given the variety of available libraries in ROS2.Walk-IT architecture runs on the ROS2 framework , which iAlthough the Walk-IT rollator in this work does not move autonomously, ROS2 has been selected because it provides a solid architecture style and communication mechanisms, as well as drivers for most commercial robot hardware. Furthermore, it simplifies evolution for future Walk-IT versions that also provide physical assistance.nodes. Nodes on the left are linked to onboard sensors, namely, right and left handle gauges, right and left odometry sensors, and the LIDAR. Nodes corresponding to commercial sensors are programmed using drivers provided by manufacturers, whereas new drivers for Walk-IT ad hoc hardware under ROS2 have been developed. These nodes publish data as topics to the system (represented by arcs), to which other nodes may subscribe.tf2 ROS2 library for tracking and management of multiple coordinate frames over time. The ROS2 tf2 library keeps track of location data in a buffered tree structure, allowing transformation between any two coordinate frames at any given time. It is important to note that these nodes may use different coordinate systems, so the architecture relies on the step_laser_filter node removes all laser readings outside a detection area centered around the rear side of the walker. This node is meant to detect readings corresponding to user’s legs, discarding readings from nearby obstacles. This filtering process relies on the ROS library laser_filters, which is highly efficient, makes the output available to any other nodes, and can be expanded with other filters if needed. detect_steps.Using available captured data, the rest of the nodes process information to estimate where the user’s feet are and, then, how much weight they are supporting on the support leg. First, the walker_odom calculates odometry from the left and right wheel encoder sensors. This node works under the assumption that the rollator can be considered a differential drive, as front wheels are actually caster wheels. Differential drive kinematics allow to obtain translational and rotational speeds from wheel speeds, and, from those, current walker position.Node detect_steps uses the filtered laser scans to find legs’ position and speed. detect_steps node fits laser reading points within the detection area into two clusters—one for each leg—using OpenCV random forest classifier. After these clusters are established, leg positions are given by the centroids of the clusters. Legs are tracked over time to obtain their velocities Node partial_loads is in charge of this task. Weight on handlebars is directly provided by topics left_handle and right_handle.Finally, weight on the support leg is the difference between user’s weight and supported weight detected on the handlebars. The node partial_loads node and uses system odometry to obtain the necessary values to calculate the spatiotemporal parameters as described in In order to implement the proposed spatiotemporal gait parameter algorithm, a new node is added to this basic architecture. This node simply subscribes to the output of the This section presents preliminary results with eleven volunteers  to illusslowest one in terms of the relative speeds.In this section we will describe in detail how leg speed information can be used to assess gait parameters, focusing on a healthy user (1) and one with some existing condition (2). It can be observed that user 1’s gait is quite symmetric, with minor, non-consistent changes from one leg to the other. Double support events are shorter with sharper transitions between feet. On the other hand, user 2 presents a lower, more homogeneous rollator speed, but significant gait asymmetries: his right leg presents a lower speed that the left and his right leg support time is significantly lower. Additionally, speed changes are smoother, with longer times spent in double support than with user 1. This is consistent with clinical evidence: users with this kind of disability tend to walk slower, more carefully, and support less weight on the affected extremity.opposite leg load for convenience.Once the support leg has been identified, the partial weight-bearing is obtained as the difference between the user’s weight and weight supported on the rollator handlebars depending on the maneuver, i.e., how fast they are steering the rollator. As expected from a user with no weakness in the lower limbs, user 1 supports very little weight on handlebars, plus variations from average are minimal for left and right leg and practically do not depend on the maneuver. User 2, on the other hand, presents major asymmetries. It can be observed in Finally, we present obtained spatiotemporal gait parameters for all volunteers in the test . As mostse cases .Design of the proposed open license smart rollator has been optimized for (i) low cost; (ii) minor laterations to the original structure, and (iii) extraction of meaningful information from users’ gait using only onboard sensors. The first two goals have been achieved, because the whole system is under EUR 500 (rollator frame included) and, according to users and clinicians, there is no significant difference between using this smart rollator and a conventional one. In order to prove the third goal and also to test flexibility through modularity, partial weight bearing and spatiotemporal gait parameters have been extracted, as presented in the previous section.Regarding partial weight bearing, persons with physical disability in their lower limbs reportedly support more weight on the rollator frane and have a symmetrical gait. This fact is supported by our tests in Regarding spatiotemporal parameters calculation, as commented, the authors already proposed a method based uniquely on weight supported on handlebars, but it was only reliable when users supported significant weight on the rollator, i.e., persons with mild to severe physical disabilities. Using the Walk-IT rollator and the proposed laser-based method, spatiotemporal gait parameters are consistent for all users. In general, average Volunteer 2’s results deserve further analysis because, although he is in the younger group, he has the higher disability degree among all volunteers and large experience with rollators . His spatiotemporal parameters are consistent with a right leg injury, i.e., his stride length is low for his age and height, his steps are very regular (very low variation), and his right steps are slower than the left ones.Finally, it needs to be noted that results for volunteer 6 are not coherent for her age, height, and condition, nor with visual observation of her test. This probably happened because she was the only volunteer wearing a long skirt that, most likely, interfered with the leg detection algorithm.Future work will focus on two important aspects: (i) to establish a sound benchmark to validate key parameters of interest, and (ii) clinical validation of the current Walk-IT implementation with volunteers presenting different disabilities in hospitals and/or residences. We expect to achieve the first goal by using a reliable motion capture system in parallel with the rollator to establish a ground truth. Validation in hospitals requires safe, healthy conditions and approval of tests by their ethical committee, which largely depends at the moment on COVID-19 evolution. One limitation for the proposed gait analysis algorithm is that it relies on detecting the legs within the laser detection range. We will explore ways to fuse laser-based step detection with other sources to improve the overall reliability of the gait assessment.We are also interested on extending Walk-IT capabilities to provide physical assistance to users by adding new hardware modules to adaptively brake the wheels (passive assistance).A system designed for easy replicability. Walk-IT relies on open software and off-the-shelf commercial components that can be easily replaced by similar ones, and it can be mounted on any standard rollator frame. In addition, hardware modules have been designed to be added to the base structure, so its original properties are not affected.A fully modular system. Walk-IT modules can be deployed/replaced on a need basis depending on the target application. In the present work, the Walk-IT basic configuration has been adapted for partial weight-bearing assessment, i.e., to measure how much weight a given user loads on each leg. Dynamic weight distribution is a very important parameter in clinical rehabilitation.An spatiotemporal analysis tool. Spatiotemporal gait parameters are reportedly linked to condition, so a spatiotemporal gait parameter capture algorithm based on leg detection has been implemented by including an additional node in the proposed ROS2 architecture.This work has presented the Walk-IT platform, a new, low-cost open-source smart rollator under ROS2. The main contributions of Walk-IT are as follows:This work has also presented a preliminary validation process. The system was tested by 11 volunteers, and results were consistent with expectations reported in the state of the art. Although extensive clinical tests are required for validation, these results are consistent with clinical reports and show that (i) the Walk-IT architecture gathers information as expected, and (ii) it can be easily modified with new sensors and modules for further uses.The main drawback of the proposed system is that laser-based gait analysis requires visibility of the user’s legs, so it is not valid for people wearing long skirts or dresses. This drawback is intrinsic to the algorithm, so the method needs to be improved by adding other sensors or by combining information with weight bearing for users who support enough weight on the handlebars.


Intensive care unit (ICU) survivors suffer from physical weakness and challenges returning to daily life. With the importance of rehabilitating patients in the pediatric intensive care unit being increasingly recognized, we evaluated the prevalence of physical and occupational therapy (PT/OT)-provided rehabilitation and factors affecting its use.We conducted a retrospective cohort analysis of rehabilitation between 2013 and 2019 using the Korean National Health Insurance database. All patients aged 28 days to 18 years who had been admitted to 245 ICUs for more than 2 days were included. Neonatal ICUs were excluded.Of 13,276 patients, 2,447 (18%) received PT/OT-provided rehabilitation during their hospitalization; prevalence was lowest for patients younger than 3 years (11%). Neurologic patients were most likely to receive rehabilitation . Longer ICU stay (versus ≤ 1 week) was associated with rehabilitation . Mechanical ventilation >2 days  and hemodialysis  were negatively affecting factors.Prevalence of rehabilitation for critically ill children was low and concentrated on patients with a prolonged ICU stay. The finding that mechanical ventilation, a risk factor for ICU-acquired weakness, was an obstacle to rehabilitation highlights the need for studies on early preventive rehabilitation based on individual patient needs. Pediatric survivors of critical illness suffer from post-intensive care unit (ICU) syndrome, which encompasses physical, cognitive, and mental health impairments , 2. ThosEarly and progressive ICU rehabilitation is a promising therapy to prevent and mitigate the functional impairments that survivors of pediatric critical illness face . Early pEarly mobilization is one of the key elements of the ABCDEF bundle, which improves ICU outcomes . HoweverEvery year, 76 in every 100,000 Korean children are admitted to an ICU and are at risk of possible impairments . KnowingWe conducted a nationwide retrospective cohort analysis using the Health Insurance Review and Assessment (HIRA) database from January 1, 2013, to July 31, 2019. In Korea, all citizens are covered by the National Health Insurance Service or Medical Aid Program . Claims In our database study sample, we included patients younger than 18 years and admitted to the ICU at least once . We defined ICU admission using the presence of mandatory claim codes  in the HThe prevalence of each PT/OT-provided rehabilitation was evaluated by the presence of cost claim codes in the reimbursement requests during hospital admission . All types of rehabilitation claim codes were based on a specific therapist-provided session. PT was defined as the presence of PT claim codes. OT was defined as the presence of OT claim codes. We defined PT/OT-provided rehabilitation as the presence of either PT or OT codes .th edition, a modified version of the International Classification of Disease, 10th edition [Information on primary diagnosis, procedures, and prescriptions was based on HIRA claim codes. Primary diagnosis was defined as the condition primarily responsible for the patient’s need for treatment. This diagnosis was documented in accordance with the Korean Classification of Disease, 6 edition . In thisProcedures of interest were evaluated according to Korean National Health Insurance procedure codes. Use of mechanical ventilation, high flow nasal cannula, extracorporeal membrane oxygenation, hemodialysis, a central venous catheter, or a Foley catheter was designated by claim codes . BecauseInformation on hospital characteristics was obtained from the HIRA Medical Care Institution database. Hospitals were categorized as tertiary hospitals, general hospitals, and other hospitals according to hospital bed and specialty numbers as defined by the Korean Health Law. Hospital region was categorized as capital (Seoul), metropolitan, or province. Metropolitan areas included Busan, Incheon, Daegu, Gwangju, Daejeon, and Ulsan. Bed-to-nurse grade was divided according to HIRA reimbursement classification and a previous study . The bedt-tests were used to compare categorical and continuous variables, respectively.Patients were divided into two groups based on presence or absence of PT/OT-provided rehabilitation during hospitalization. We used mean and standard deviation or median and interquartile range to describe the distribution of continuous variables. Chi-squared tests and Student’s We conducted random-effects logistic regression to identify univariate and multivariable predictors for PT/OT-provided rehabilitation. Odds ratios (OR) with 95% confidence intervals (CI) were estimated using the model. We used univariate random-effects logistic regression analysis to identify possible predictors of PT/OT-provided rehabilitation. Then, we developed a multivariable model that included age, sex, tertiary hospital, ICU LOS, bed-to-nurse grade, emergency room, region, admission department, primary diagnosis, and procedures during hospital admission .-Value < 0.05 as statistically significant for all analyses. Statistical analysis was carried out with SAS and Visual Analytics.We considered a pOf the 13,276 patients who met inclusion criteria and were admitted to 245 Korean ICUs, 2,447 (18%) received PT/OT-provided rehabilitation at any time during their hospital stay. PT was used more frequently (18% of pediatric patients in 2013 and 20% in 2018) than was OT (6% in 2013 and 7% in 2018). Provision of PT/OT increased significantly over time, from 18% to 20% between 2013 and 2018  and hemodialysis  were less likely to receive PT/OT-provided rehabilitation.In this national Korean cohort study, the prevalence of inpatient PT/OT-provided rehabilitation for critically ill children was low and varied widely according to ICU LOS. In addition, patient demographics, procedures, and hospital characteristics were associated with PT/OT-provided inpatient rehabilitation. Our investigation into current implementation of pediatric critical care rehabilitation, a subject rarely studied in Asian countries, suggests that current practice status may not be enough in amount and may not meet clinical timeliness.We found that critically ill children with a longer ICU LOS had more frequent PT/OT-provided rehabilitation. Longer ICU LOS might have been the reason for the higher prevalence of PT/OT involvement, as muscle strength decreases with increased duration of bed rest . An incrPatient age and diagnosis affected the prevalence of PT/OT-provided rehabilitation. Younger children received less frequent PT/OT, as reported in other studies –14. HoweDiagnosis of congenital anomaly was a negative predictor of PT/OT-provided rehabilitation. Most patients with a congenital anomaly were infants or younger children . TherefoVarious procedures can affect inpatient rehabilitation implementation. Use of mechanical ventilation for more than 2 days and renal replacement therapy were positive predictors in unadjusted analysis. However, both procedures turned into negative predictors of PT/OT-provided rehabilitation when we adjusted for the length of ICU stay in addition to other conditions. It is possible that patients under one of these 2 procedures were more severely ill, so they stayed longer and received more rehabilitation than the other patients. However, when the length of ICU stays was equal, these patients received less rehabilitation compared to the patients without these 2 procedures. Endotracheal intubation and other invasive devices were reported as a barrier to out-of-bed mobility in previous studies, but the effect on overall in- and out-of-bed PT/OT was variable –14. The However, ventilated patients have a greater need for PT/OT-provided rehabilitation than do other patients. Long-term mechanical ventilation is associated with higher functional impairments and more critical illness-related neuromuscular abnormalities , 29. MusHospital organization can affect rehabilitation prevalence, and nursing has a central role in rehabilitation . In prevOur study has several limitations. First, because the database used in this study was from claims for insurance reimbursements, we could not evaluate important parameters such as patient severity or level of PT/OT-provided rehabilitation. In addition, no information was provided regarding the initial hospital day or location of PT/OT-provided rehabilitation. It was difficult to distinguish whether PT/OT-provided rehabilitation was a preventive measure or initiated after observation of functional impairments. Therefore, additional studies will be needed to determine the prevalence and predictors of early rehabilitation in critically ill children. Second, this study was conducted in a country that has a national health insurance system. Therefore, the results might not be generalizable to other countries with different rehabilitation costs or resource settings. However, we evaluated all children admitted to the ICU, which is crucial for a prevalence study. In addition, our findings suggested predictive factors for PT/OT-provided rehabilitation and a possible discrepancy between feasibility and requirements of PT/OT-provided rehabilitation in critically ill children.In conclusion, prevalence of rehabilitation for critically ill children is low in Korean ICUs and affected by ICU duration and device support, raising concerns about whether the clinical needs of patients are being met. Additional studies on the timely and systematic implementation of implementation of therapies to meet rehabilitation needs of these critically ill patients are urgently needed.S1 Table(DOCX)Click here for additional data file.