Mage = 22.40, SD = 2.25) from two male teams. Two training sessions with four tasks  in counterbalanced order between teams were completed. To achieve a goal during limitation tasks, a minimum number of players had to participate in the passes before the goal. Internal (perceived effort and heart rate) and external physical load (distances), mental load  and fatigue (VASfatigue) were quantified. Paired t-test and magnitude-based inference were conducted. The results showed significantly higher mean speeds (p < 0.01), effort perception (p < 0.001), and mental fatigue (very likely positive) during possession games with restrictions. Additionally, performance satisfaction obtained significantly higher values with goalkeepers and pass restrictions (very likely positive). External physical load showed no significant differences between situations. The influence of mental fatigue on internal load and the complexity of the tasks could explain these results. Coaches can use this information to manipulate the training load in ecological conditions.This study aimed to analyze the effects of rules limitations in pass decisions during soccer tasks on physical and mental load reported by players. Participants were 40 semiprofessional Spanish soccer players ( Specific soccer strategies such as the number of players involved, the scoring system, or the size and orientation of the pitch could vary according to the coach’s objectives during training tasks . AlthougWithin the current soccer training approach, physiological, psychological, and technical-tactical elements are interrelated  to obtaiIt has been shown that larger pitch size increases the physical load of the soccer tasks in terms of total distance and heart rate ,13,14. AHowever, to our knowledge no previous studies have analyzed the influence of added rules in pass decisions  on physical and mental load, although this strategy is frequently used during soccer tasks. First, we hypothesize (1) that the restrictions in pass decisions will increase the internal and external physical load of the soccer tasks. To justify this hypothesis, we highlight that previous studies that used constraints like the limitation of ball touches or unbalance have observed an increase in one vs. one duels, the distance covered, and Rated Perceived Exertion Scale (RPE) values ,26,27. AWe consider that the present study could contribute information about how restrictions in pass decisions may affect the training load. This information can increase the control of the load changes produced by this frequently used constraint, so it can be important for coaches and practitioners. This study aimed to analyze the effects of rules in pass decisions on the physical and mental load and fatigue of soccer training tasks. Mage = 22.90, SD = 5.60) belonging to the Third Spanish League (n = 20) and the u-18 First Spanish League (n = 20). All of them participated voluntarily in the study. The two teams performed four training sessions per week (ranging between 90 to 100 min), and all players had a minimum soccer experience of 14 years. Respect to the inclusion criteria of the players, we consulted previous experts [Participants were 40 semi-professional soccer players from two Spanish male teams , the Polar Team Pro, a global position system (GPS) was used. This technology is based on a signal concentration system of different Polar brand sensors, designed for the control and monitoring of physical activity in collective sports like soccer or basketball. This technology has been validated [To analyze mean and peak heart rate, mean and peak speed, distance/minute, and the number of sprints  to 10 (maximum exhaustion), and its use and accuracy in soccer tasks has been proved [The Rated Perceived Exertion Scale (RPE) was used to quantify the perception of effort by soccer players. This instrument has been used to control the internal physical load, through the registration of the player’s exhaustion level after a physical or sports activity. The RPE includes values ranging from 0 (n proved .no load) to 10 (maximum load) for each item described. The validity of this instrument in soccer has been demonstrated in previous studies [To analyze the mental load, an adaptation of the NASA-Task Load Index (NASA-TLX) was used. The original NASA- TXL is one of the most used scales in organizational psychology. Specifically, this adaptation asked about specific soccer-related mental and physical effort, time pressure, performance satisfaction, general effort, unsafety, and interaction. This instrument includes values from 0  to 100 (maximum fatigue perceived) and players indicated their general fatigue perception. Participants were instructed to “Please mark the point in the line that represents your current state of mental fatigue.” The accuracy of this scale has been proven in soccer samples for the purpose described herein [The Visual Analogue Scale 100 (VAS100) was used to quantify the mental fatigue perception of the players . Originad herein .All research procedures were conducted in accordance with the Declaration of Helsinki  and had the approval of Ethics Committee for Research with Human Beings. . All participants were informed about the objective of the study and signed informed consent. Two training sessions (A and B) with four tasks were completed by each team. This intervention was carried out at the mid-season phase . The first experimental session was developed three days after the last match (on Wednesday), whereas the next match was played three days after the first experimental session had finished. The second experimental session was performed exactly one week after  the first session was performed, with the same pre- and post-match rest days, as explained. These training sessions included the same type of task with a modification in the score system constraint: Tasks 1 and 2 were MBPG, whereas Tasks 3 and 4 were MBPG-G. A restriction in pass decisions was included in one of each type of task per session (one MBGP and MBPG-G with pass limitations and one MBPG and MBPG-G without pass limitations per session). The manipulation of the limitation in pass decision was implemented by the next condition: a minimum number of players  had to participate in the passes before achieving the goal . Additionally, to control the residual effects, the tasks were presented in counterbalanced order see  between p-values and MBI) is based on Holgado et al.’s affirmation according to previously reported data about the statistical negative effects of mental fatigue on physical performance or the fatigue that could have been caused by statistical errors [The statistical program SPSS 25.0 (2017) and Hopkins’ (2017) specific pre-post cross-over spreadsheet were used to analyze the data obtained . Data wel errors . The comparison between internal physical load values is shown in p-value analysis, only time pressure in the MBPG showed significant changes, with higher values in the limitation tasks. However, according to the MBI analysis, mental effort and fatigue for MBPG and performance satisfaction during MBPG-G showed very or most likely changes with higher values in tasks with pass limitations. Mental effort represents the real mental resources that the players use to achieve the goal and it produces mental fatigue Thus, the relation between these variables is clear. The rest of the mental variables (unsafety and interaction) compared for these two types of tasks did not show relevant differences , although all results were higher for these variables in pass limitation conditions, both in the MBPG and the MBPG-G score system.Finally, descriptive values and the comparison of pairs of tasks for mental variables are presented in The purpose of this study was to analyze the effects of limiting pass decisions on physical and mental load and fatigue during soccer training tasks through a rule stating that the goal is only valid if a minimum number of players participate in the passes before achieving the goal. Thus, we proposed two training sessions with the same tasks (with or without the constraint) and compared their results. The main findings of the study suggested that RPE and mental fatigue levels were affected by these constraints because higher values were found in these variables using the limitation, especially during the MBPG score system tasks. However, the external physical load reported by players was not affected or decreased by the use of constraints in pass decisions, either in MBPG or MBPG-G.We expected (Hypotheses (1) that the limitation in pass decisions would increase internal and external physical values. Indeed, internal load results were higher during the limitation tasks. However, contrary to the hypothesis, most of the external physical values were higher or unchanged in no-limitation tasks. Previous research showed synergistic increases/decreases both in internal and external physical load with the use of soccer constraints like the size of the pitch ,11,15. HOn another hand, the disagreement between the decreases in external load and the increases in the internal load values could be explained by the mediated effect of mental fatigue. This explanation is justified by the psychobiological model. This model is characterized by increases in internal load (RPE) values without increases in external load . AccordiConcerning mental values, we expected (Hypothesis (2) that the limitations in pass decision would increase mental load and fatigue. Specifically, the results confirmed that mental and physical effort, time pressure, and mental fatigue increased in MBPG. Additionally, positive and significant changes in performance satisfaction were obtained for MBPG-G. The increases in mental load values due to the pass decision constraint could be influenced by the extra mental effort that this limitation produces in players because they must increase their attention and cognitive levels to achieve the objectives and conditions of the training tasks. Other previous studies confirmed that the task’s entropy can increase with the use of soccer constraints like the scoring system  or the tConcerning mental fatigue, it is difficult to find studies to discuss the results found, because most of the studies published do not use specific soccer strategies. In this sense, Thompson et al. (2020) proved that the use of Stroop tasks before measuring sports performance has increased knowledge about mental fatigue, but mental fatigue accumulation does not occur before matches; the accumulation of mental fatigue occurs during and after soccer matches. The importance of studies that increase the information and practical applications about how coaches can manipulate mental fatigue with specific soccer strategies has been highlighted by these authors. Moreover, the control of these types of fatigue is very important because an important increase in the accumulation of mental fatigue levels can reduce soccer performance .Probably, the main limitations of the study were the exclusion of the previous training mental fatigue levels and the effective time of practice. In future research, the quantification of prior mental fatigue levels (before the task) could increase the information obtained. Additionally, the inclusion of the effective time of practice and information about all types of fatigue. Another interesting aspect is the implementation of this intervention at different moments of the season , because the training load is not the same during the whole season. The different influence of this constraint on the types of tasks may also be considerable.On the other hand, in future studies it could be interesting to analyze the implementation of this constraint during more training sessions or other types of tasks, different from MBPG and MBPG-G, comparing the types of tasks. Additionally, it would be interesting to compare the fatigue that different tasks induced. Future research should examine the differences between these results and the findings obtained with professional players or even the quantification of the effective practice time.In our opinion, these results add important information for researchers, practitioners, and coaches about the use of this constraint. The use of this limitation in pass decisions is a frequently used strategy during soccer training sessions, and based on the effects reported in this research, coaches can use this specific soccer constraint to manipulate the load according to their objectives. The present study confirmed that the use of pass restrictions during soccer tasks may modify the effort perceptions and mental fatigue reported by players during soccer training sessions. Specifically, these variables increase with the use of these restrictions, with higher effects in MBPG tasks than in MBPG-G. These increases are probably mediated by the effect of mental fatigue on internal physical load, because the values of the external physical load were not modified. The cause of these unchanged values of external values could be the decreases in effective practice time, which could be caused by the complexity of this constraint or the player’s level.


Anteosaurus. Here we examine the bone microstructure of multiple skeletal elements of Anteosaurus from the Tapinocephalus Assemblage Zone of the Karoo Basin. The bone histology of Anteosaurus magnificus reveals that the cortex is composed of highly vascularized, uninterrupted fibrolamellar bone tissue surrounding the inner spongy medullary region. However, the histology of two ribs and a previously described femur of another Anteosaurus taxon revealed an interrupted growth pattern with lines of arrested growth and peripheral rest lines occurring in the compacta, indicating periodic pauses in growth possibly linked to the slowing down of growth during maturity. Given that the fibula of the same individual has well-vascularised fibrolamellar bone tissue without any growth marks in the cortex; this suggests variation in skeletal growth. Based on our histological results, three growth dynamic stages are deduced for the genus Anteosaurus: (i) the earliest growth stage is represented by the predominance of highly vascularized, uninterrupted fibrolamellar bone tissue in the inner cortex, which suggests rapid periosteal bone deposition during early ontogeny; (ii) the next stage of growth shows periodic interruptions in the bone deposition as indicated by the deposition of lines of arrested growth; (iii) the third stage shows the development of lamellar bone tissue with rest lines in the peripheral part of the cortex suggesting a slowing down of growth prior to death. Most of the skeletal elements are characterized by thick bone walls, extensive secondary reconstruction and the complete infilling of the medullary cavity. However, the radius and a previously studied femur have open medullary cavities with struts of bony trabeculae. Based on histologic structures and comparisons with extant taxa, it is likely that Anteosaurus may have been more terrestrial as its osteology point towards terrestriality, but it may have occasionally inhabited ephemeral pools like modern semi-aquatic Hippopotamus.Despite its abundance in the Permian fossil record of South Africa, little is known about the life history of  Australosyodon, Notosyodon and Syodon) and Anteosaurinae  with Russian taxa Archaeosyodon and Microsyodon representing the most basal anteosaurs , first appeared during the Middle Permian  and formed a key component of the terrestrial tetrapod fauna . The famteosaurs . Liu  and internal tissue structure (histology) varies according to lifestyle adaptations . Furtheria parva . More reJonkeria  and havee.g., e.g., Anteosaurus taxa. Our study aims to assess the inter-elemental variation in their bone histology as well as to shed light on their lifestyle adaptations.Since tetrapods display a wide range of histological characteristics e.g., , 2012, aTapinocephalus Assemblage Zone of the South African Karoo Basin (Anteosaurus magnificus whereas the fibula (BP/1/5591b) and ribs (BP/1/5591c–d) belong to another Anteosaurus taxon. All specimens were obtained from Iziko South African Museums, Cape Town, and Evolutionary Studies Institute (formerly the Bernard Price Institute) at the University of the Witwatersrand, Johannesburg, South Africa. Permission to section the fossils was obtained from the South African Heritage Resources Agency .The specimens studied here were excavated from the oo Basin . For ouroo Basin  were exaTransverse sections were prepared from midshaft levels wherever possible as these are the regions of the bone that undergo the least amount of secondary remodeling  and limbe.g., ends of the bone/broken regions) and therefore this prevented us from sectioning both proximal and midshaft regions from the same element. After the cores were obtained, the holes were infilled with plaster to preserve the overall morphology of the bone. Depending on the fossil itself, each core was either embedded in an epoxy resin  in the bone deposition, while the third stage shows a marked slowing down of bone deposition and overall growth as indicated by the presence of several peripheral rest lines. Most of the skeletal elements are characterized by thick bone walls, extensive secondary reconstruction and the complete infilling of the medullary cavity. The radius of Anteosaurus magnificus and previously studied femur of Anteosaurus sp. have open medullary cavities with struts of bony trabeculae. Based on the mixed histological features evident in the skeletal elements studied , and considering the previous oxygen isotopic studies , South Africa. Abbreviations: SAM, Iziko South African Museums, Cape Town, South Africa; BP, EvolClick here for additional data file.


Chitin and its deacetylated derivative chitosan are amino polysaccharides of great interest due to their biological and technological properties. Chitosan composites using myriad components have been produced to improve chitosan-based materials . By seleIn this Special Issue, several examples of chitosan-based composites are presented with different purposes.Osorio-Madrazo and co-workers explore fibre-reinforced hydrogels to be used for the repair and regeneration of the intervertebral disc (IVD) annulus fibrosus (AF) tissue . The choIn the second contribution, chitosan composites are produced with polyaniline powders using a solution casting method . The add2+ ions from tap water and wastewater avoiding the drawbacks of iron oxides [Access to safe drinking water is a fundamental need and human right. The treatment of wastewater is a serious concern, so materials designed to clear water are gaining large interest. It is well known that iron oxides are very potent sorbents for a variety of elements that include strontium. However, in solution at basic pH, they exhibit poor mechanical properties and stability. In the third paper, chitosan composites containing iron oxides are produced to eliminate Srn oxides .Metallic chitosan-based composites can be easily produced using chitosan both as a reducing and stabilizing agent. However, the control in the production of the nanoparticles depends on the physicochemical properties of the chitosan used. This effect is poorly studied in the literature and mainly ascribed to chitosan Mw and deacetylation degree. Aranaz and co-workers demonstrated that the chitosan pattern also affects the process of AgNPs production in terms of nanoparticle size and stability . This wiIn the last paper, Goycoolea and co-workers reviewed the interaction between mucins and chitosan in order to gain deeper knowledge of the mucoadhesive properties of chitosan . This pr


Analysis of scoliosis requires thorough radiographic evaluation by spinal curvature estimation to completely assess the spinal deformity. Spinal curvature estimation gives orthopaedic surgeons an idea of severity of spinal deformity for therapeutic purposes. Manual intervention has always been an issue to ensure accuracy and repeatability. Computer assisted systems are semi-automatic and is still influenced by surgeon’s expertise. Spinal curvature estimation completely relies on accurate identification of required end vertebrae like superior end-vertebra, inferior end-vertebra and apical vertebra. In the present work, automatic extraction of spinal information central sacral line and medial axis by computerized image understanding system has been proposed. The inter-observer variability in the anatomical landmark identification is quantified using Kappa statistic. The resultant Kappa value computed between proposed algorithm and observer lies in the range 0.7 and 0.9, which shows good accuracy. Identification of the required end vertebra is automated by the extracted spinal information. Difference in inter and intra-observer variability for the state of the art computer assisted and proposed system are quantified in terms of mean absolute difference for the various types  of scoliosis. Scoliosis is pre-dominantly observed in teen age children. The causes for scoliosis can be conditions such as congenital, cerebral palsy and muscular dystrophy, however the cause for most scoliosis is not known.The three dimensional (3D) deformity of human spinal cord is referred to as scoliosis. The scoliosis is mainly characterized by the lateral curvature, which is also called as spinal curvatureThe human spinal cord consists of 33 vertebrae, which are subdivided into five different parts namely, cervical, thoracic, lumbar, sacrum, and coccyx. The scoliosis mainly affects thoracic and lumbar regions consisting of 17 vertebrae (12 in thoracic region and 5 in lumbar region). The spine in these regions, curves abnormally towards left or right side with sideways curve of the spine more than 10 degrees being considered as scoliosis. The spinal curvature ranging between 10 to 20 degrees is considered to be mild scoliosis, between 20 to 40 degrees is considered to be moderate and above 40 degree is severe scoliosis. The majority of scoliosis cases may require follow-up and watching for worsening of the curve. Certain cases may require more aggressive treatment which could include surgery. Orthopaedic surgeons are trained for the evaluation and treatment of scoliosis. The major symptoms observed in scoliosis may include pain in the shoulders, osteoarthritis, or respiratory and cardiac problems in severe cases.2. This gives raise to undesired inter-observer and intra-observer variability. So, building an accurate computer based automated measurement is essential and it is challenging for the reliable and robust assessment of scoliosis4.The degree of spinal curvature is the key measure used by the physician in the diagnosis of scoliosis. Both two dimensional 2D) and three dimensional (3D) imaging modalities such as X-rays, CT-scans, and MRIs are used for the spinal curvature evaluation. The 2D imaging based on X-rays has advantage over other imaging techniques is that it require less capturing time, less radiation effects and is cost effective. Also, radiography images have been extensively used and proved to be successful in the analysis and evaluation of 3D deformities of scoliosis. Another advantage of radiography is that its ability capture the entire spine in the standing position. Standing radiography images are more reliable for the accurate measurement of the spinal deformity. There are several methods for the measurement of internal curvature of the spine trunk, which include Cobb, Diab, Centroid, Greenspan, and Ferguson methods Figs. , 2. AmonD and thr6. This work proposes automatic extraction of anatomical features to interpret required end vertebral definition for the computer assistant algorithm in terms of medial axis and central sacral line for the curvature estimation. The proposed algorithm for the extraction of CSL and MA are equally applicable to King’s as well as Lenke classifications.Cobb method estimates the spinal curvature by drawing a straight line which is tangent to the upper end plate of superior end-vertebra and lower end plate of the inferior end-vertebra . This study concludes reliable assessment of Cobb angle measurement by the pre-selection of upper and lower end vertebrae.Hitesh et al. proposed reliable assessment of Cobb angle for juvenile and adolescent idiopathic scoliosis in 200913. Set of scoliosis radiographs are used to train the software for the recognition of the vertebrae. Training part includes boundary description in terms of manual digital landmarks around the perimeter of the vertebrae.Cobb angle measurement using Active Shape Model (ASM) is proposed by Shannon et al., in 2008 for idiopathic scoliosis14. Reliable analysis of spinal curvature using Cobb angle has been studied by Eiten et al.15. Their study uses Picture Archiving Computer System (PACS) for precise definition of anatomical landmarks for angle measurement which includes indices, length of joints, limbs and spine. This results in decorrelation of required bony landmarks as insignificant information.Junhang introduced Hough transform and snake model for Cobb angle and vertebral rotation. These algorithms were integrated with shape priors to improve the performance of evaluation. Since selection of end vertebrae was a possible source of error that had no relation to the technique involved in the Cobb measurement, end vertebrae were pre-selected in this study5 to ensure that reliable measurement of Cobb angle using digital and manual, which conveys that the assessment is an important parameter in-terms of posterior–anterior radiograph. This study also encourages use of digitized radiograph for routine clinical practice. This report also illustrate the clinical advantage for appropriate assessment of spinal curvature which is an unsolved problem in end-vertebra selection.Technical report has been submitted by16 introduced a novel framework to detects vertebrae as objects, that estimates the 4 landmark corners of each vertebra separately. Their approach was promising because they are predicting the vertebrae before the landmarks. However, cropping all test images will not generalize as more robust object detector trained with images having negative samples from skull and pelvic regions.Bidur Khanal17 proposed CNN based network to reduce the influences of inconsistent intensity distribution of vertebrae in the spine in spinal curvature estimation, which includes the U-Net, the dense U-Net, and residual U-Net, to segment the vertebrae. Their study resulted with high correlation to manual assessment by clinical doctors.In 2017, Ming-Huwi18 and his team attempt to extract the Spine contour through deep learning approach in the feature map plane. The features used in their study includes gradient magnitude and gradient histogram. Extraction of these features vary exponentially in the scoliosis pattern, which misleads the decision process. As idiopathic scoliosis is a structural deformity, its deformity is clearly visible in the anterior- posterior view, as it is directly exposed to radiation plane.In 2019, Yongcheng19, performed vertebrae segmentation and labelling using progressive U-net. They imposed minimum size on the number of contour pixels. Proposed progressive U-net illustrates the Cobb angle estimation.Abdullah-Al-Zubaer Imran and his team in 2020This study was conducted in collaboration with department of Orthopaedics, Kasturba Medical College, Manipal, completed in 2015. The experiments were performed in accordance with the hospital guidelines. This study involves anonymized antero-posterior radiographs of adolescent idiopathic scoliosis. This study was approved by Departmental Review Committee, Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education (MAHE). This study was done before the revised guidelines for research in lndia (lCMR 2017) were released. For retrospective studies, KMC and KH Institutional Ethics Committee waivers informed consent from the patient/parents. As it was a low risk study, only Departmental Review Committee approval was sought, and it was exempted from approval by the KMC and KH Institutional Ethics Committee.20.Structural deformity of spinal column in the lateral direction leads to scoliosis disorder. The displacement of the spinal column from the original position to the new position has been evaluated in terms of medial axis and central sacral line. The medial axis or spinal mid-line (MA) is defined as the curve passing through the centroids of the vertebral bodies  radiographs of 250 patients with idiopathic scoliosis are used for the study obtained from the department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education (MAHE), Karnataka, India. These radiographs are taken in a conventional standing posture at a fixed distance of 228 cm from X-ray source. These AP radiographs includes thoracic, thoracic lumbar and lumbar scoliosis with all five different types of scoliosis. Radiographic images of 256 gray levels with size of 925 pixel heights by 475 pixels wide are used.Two hundred and fifty cases of adolescence idiopathic scoliosis are considered in the present study. The cases considered are recorded in the first visits and the study is performed over a period of 3 years. Congenital and neuromuscular spinal deformities are excluded from the study.Manual definition of CSL and MA are time consuming and imprecise. The point to point correspondence between CSL and MA defines required superior, inferior and apical vertebrae. Proposed methodology extract the CSL and MA for the automatic identification of the vertebral parameters for the different spinal curvature estimation techniques as shown in Fig. Optimum global threshold removes all the other pixels with higher intensity in the pre-processing step. The pre-processed image will be a binary image with white pixel region enveloping a minimal extraneous content. Logical operators are applied to retrieve back the original X-ray features localized to the enveloping region. To partially suppress the unnecessary side information, interpolation has been proposed in terms of fast Fourier transform (FFT) method. And this FFT method adds interpolated data to the original data as shown in algorithm1.Algorithm 1 Extraction of Spinal ColumnErosion operation has been performed on the resultant image after the extraction of the spinal column. Then subtract the eroded image to result into two boundaries, out of which large boundary had been chosen. Boundary operation is done with Gaussian filter and finally convert them into binary image. This algorithm is summarized and is as shown in Algorithm 2. As digital technology continues to advance and become increasingly affordable, digital radiograph analysis will become common place. Contrast, sharpness and visualization details may be manipulated and enhanced with digital techniques. However the content of the radiographic film cannot be improved and landmark identification may persist.The boundary representation consists of pair of co-ordinates. For every co-ordinate there exist two X-values. The average of these two X-vales will be the X-coordinates of the medial axis. As discussed in the introduction, definition of the required end vertebrae identification is based on the deformity of the spinal column, it has been represented by MA. Quantification of MA deformity is carried out with reference to the data from its CSL. Point to point displacement between MA and CSL represents the deformity. Developed computerized algorithm reads the coordinates of CSL and MA. Computer assisted system will identify the indication of the curvature by checking the X-coordinate where exactly is it different than X-coordinate of the CSL.Similarly, the curvature endings are identified by checking once again with overlapping of X-coordinate between CSL and MA. The maximal displacement between X-coordinate of CSL and MA represents the apical vertebra.The performance of spinal curvature measurement depends on the accurate identification of anatomical landmarks. The anatomical features are automatically located by using CSL and MA algorithms. Further, the spinal curvature estimation from the obtained landmarks is done by using different methods such as Ferguson, Cobb, Greenspan and Diab. The proposed inference in terms of anatomical description for spinal curvature estimation is given in Table Manipal Academy of Higher Education (MAHE) encourages faculty members to publish their research outcome in quality journals through "Incentive for research publication" program. The corresponding and co-authors of this article are under the functional body of this program.The 250 adolescent scoliotic radiographs collected from the associated hospital have been grouped equally. Different observers are assigned to evaluate the spinal curvature using manual, computer assisted and proposed methods. Each observer is provided with all types of radiographs. In case of manual measurement, each observer is informed to identify the required end vertebrae for the best of their knowledge and experience. The experts would calculate the spinal curvature using ‘ruler and pencil’ procedure. In computerized method, identification of required anatomical landmarks (marking of superior and inferior end vertebrae) are done by the each observer independently. Estimate the spinal curvature based on the identified anatomical landmarks with the computer assistance. This computer assisted method eliminates the observer error introduced by the ‘ruler and pencil procedure’. In the proposed method, it identifies the required end vertebrae automatically. After the automated identification, observer is asked to identify the corners of the end vertebrae. This in-turn may introduce minimal observer error. Successive procedures will be taken care by computer assistance method.Consistency, or agreement among the Surgeons  arises due to the variability among human observers in the decision of superior end vertebra (SEV), inferior end vertebra (IEV) and apical vertebra (AV). In our study, agreement among the surgeons in-terms of SEV, IEV and AV definition is referred as inter-rater variability which is assessed using kappa statistic. This study includes two Junior resident who are trained for this work are adopted for evaluation. Cohen’s kappa statistic check the reliability among the vertebral labeling. The observed agreement is defined as percentage of correct labeling of anatomical landmarks . The expected agreement is based on how much agreement would be expected to be present by chance alone in the localizing the vertebrae. Each study has been carried out with 50 adolescent idiopathic radiographs. Table We have grouped the given radiographs into different classes based on the type of deformities, which includes all types of scoliosis. The resultant spinal columns are represented in Fig. The overall goal of this study is to reduce measurement error in spinal curvature estimation with different technique such as Cobb estimation, Ferguson method, Centroid method and Diab procedure. The mean absolute difference in terms of inter-observer error for manual, computer assisted and proposed methods are presented using bar charts as shown in Figs. To identify the severity of the curve, it is necessary to evaluate the inclination of the vertebral bodies. The limiting vertebrae are the most oblique one while the apical vertebra is the most rotated and wedged one. The possible errors introduced in the spinal curvature measurements are due to the identification of the required anatomical landmarks. It is difficult to draw the lines tangent to the vertebral bodies because of vertebral deformity. To reduce variability in spinal curvature measurement for the scoliosis assessment, a computerized method was developed. Proposed method automatically measures the spinal curvature on posterior-anterior radiographs. The brightness and the contrast were adjusted on the radiograph for the proper selection of top and bottom vertebrae. Continuation of this results in manual decision on the spinal curvature estimation. The end-vertebral tilt is mostly towards the concavity of the spinal column for the measurement of spinal curvature. However, the manual measurement of spinal curvature depends on experience and judgment. This results in errors due to selecting different end vertebrae and estimating different slopes of the vertebrae. In addition, the manual measurement is tedious and time-consuming. This proposed work is a new approach which extracted the MA and CSL using advanced computerized image understanding system for the decision of the required anatomical landmarks. The participants involved in testing are orthopedic surgeons, who had several years of experience. Manual marking of end vertebrae were marked for measurement with soft lead pencil and after measurement had been recorded the marking were erased with trichloracetone. Each observer took approximately 5 min to identify required end vertebrae and to estimate the spinal curvature with ruler and pencil. Each examiner recorded his choice for different groups of scoliosis radiographs. This experimental study involves different spinal curvature estimation . We have grouped each type of scoliosis into five different categories as categorized by King’s classification. Each group is defined with minimum 10 scoliotic radiograph. We assigned three participants (experienced) for the estimation process. All their measurements are tabulated for all types for every radiograph in the group. Each person comes with 30 different reading within the group . The absolute difference between these reading in each set is considered for the measurement statistics.From the result plots (refer result plots in Figs. Spinal curvature measurement needs identification of the end vertebrae. Human intervention is mandatory for deciding the end vertebral landmarks. Due to human decision at different levels inter and intra observer errors are introduced. Computer assisted systems are useful to eliminate these errors up to some extent. It works on digital reconstruction of manually identified landmarks. Current computerized system evaluates the landmarks based on the enhanced or edge detected radiographs. The proposed computerized image understanding system completely automates the quantification of the spinal curvature by the automatic definition of end vertebrae using extracted CSL and MA. These automatic extracted CSL and MA can be further extended to the estimation of thoracic kyphosis and lumbar lordosis in standard lateral radiographs, where there is no vertebral anomalies.


The reproduction of the brain vasculature is particularly challenging as numerous cell types are involved. Moreover, the blood-brain barrier, which acts as a selective filter between the vascular system and the brain, is a complex structure to replicate. Nevertheless, tremendous advances have been made in recent years, and several works have proposed promising 3D in vitro models of the brain microvasculature. They incorporate cell co-cultures organized in 3D scaffolds, often consisting of components of the native extracellular matrix (ECM), to obtain a micro-environment similar to the in vivo physiological state. These models are particularly useful for studying adverse effects on the healthy brain vasculature. They provide insights into the molecular and cellular events involved in the pathological evolutions of this vasculature, such as those supporting the appearance of brain cancers. Glioblastoma multiform (GBM) is the most common form of brain cancer and one of the most vascularized solid tumors. It is characterized by a high aggressiveness and therapy resistance. Current conventional therapies are unable to prevent the high risk of recurrence of the disease. Most of the new drug candidates fail to pass clinical trials, despite the promising results shown in vitro. The conventional in vitro models are unable to efficiently reproduce the specific features of GBM tumors. Recent studies have indeed suggested a high heterogeneity of the tumor brain vasculature, with the coexistence of intact and leaky regions resulting from the constant remodeling of the ECM by glioma cells. In this review paper, after summarizing the advances in 3D in vitro brain vasculature models, we focus on the latest achievements in vascularized GBM modeling, and the potential applications for both healthy and pathological models as platforms for drug screening and toxicological assays. Particular attention will be paid to discuss the relevance of these models in terms of cell-cell, cell-ECM interactions, vascularization and permeability properties, which are crucial parameters for improving in vitro testing accuracy.Tissue vascularization is essential for its oxygenation and the homogenous diffusion of nutrients. Cutting-edge studies are focusing on the vascularization of three-dimensional (3D)  For decades, the construction of vascularized tissue has been a major challenge in 3D tissue engineering for non-animal alternatives. Vascularization is essential to supply thick tissue (>100–200 μm) with sufficient oxygenation to allow their long-term maintenance, and conduct, for example, toxicity assessments in sub-acute and sub-chronic conditions . The BBB forms indeed a protective barrier, located at the cerebral capillary endothelial cells. This barrier helps maintain the homeostasis of the central nervous system (CNS) by tightly regulating the entry of molecules, ions and cells, and is essential for proper neuronal function , compared to the 94% coverage obtained with the conventional chemical fixation method , shown to decrease the expression of TJs like Zonula Occludens-1 (ZO-1) , due to their limited ability to form complete formation of TJs. This spheroid model also failed to accurately correlate the permeability of cell penetrating peptides between in vitro human model and in vivo mice model. This lack of predictability could potentially result from the model configuration or from the species differences between both models. The spheroid technique could be improved to elaborate more complex human cortical structures. Nzou et al. cultured six cell types  forming an engineered NVU, which could serve as a platform for neurotoxicity assessment , poly(hydroxyethyl acrylate), poly(methacrylic acid)  where a synthetic polyester membrane creates a separation between cells  before flow perfusion. The devices generally contain at least two compartments: one with these ECs, and one with supporting cells separated by a porous membrane    and the basal-to-apical permeability (PB/A) can be determined by analyzing the concentration of tested molecules in the lower and upper chamber of the culture insert. The influx transport in both compartments of the Transwell® model can be identified by the measurement of PA/B and PB/A.The ratio of PA/B and PB/A is a quite good indicator of the efflux transport through the BBB. However, the ECs in Transwell® models can exhibit higher permeability and lower expression of efflux transporters compared to in vivo  is a 170 kDa ATP-dependent pump known to have good affinity for a broad range of molecules, including lipophilic or amphiphilic molecules such as anticancer drugs   is the most abundant and important regulator of angiogenesis in various primary brain tumors, including GBM. Zhao et al. recently showed that hypoxic GBM-derived exosomes containing multiple pro-angiogenic factors including VEGF-A, can induce the proliferation of ECs and angiogenesis. VEGF mediates the increased permeability of the BBB model by reducing the expression of TJ proteins, thereby constructing a suitable environment to support tumor nutrition and proliferation . Intermediate and long-term studies are however currently greatly lacking in most of the current works. Kinetics data can greatly help to determine the success of in vivo studies, predict metabolic stability of drugs and give insights about their intrinsic clearance from the body.Other type of treatments such antipsychotics, widely used to manage psychoses that occur with schizophrenia and bipolar disorder have adverse effects on the BBB ECs. Four kinds of antipsychotics  were applied on 2D culture of brain ECs at typical therapeutic concentrations for high dosage treatment. All four antipsychotics showed impairment of cells morphology, increased apoptosis, and decreased of the transcytosis of Evans blue on brain ECs (Elmorsy et al., in vitro models aim to bridge the gap between in vitro and in vivo. So far, a trade-off is still often made between complexity and the standardization of the preparation process. The ECM composition and the influence of mechanical shear stress on ECs are increasingly being taken into consideration in brain microvascular engineering. Newly developed 3D models could moreover be of great interest to better understand the tumoral impacts on the microvasculature, and design the next-generation of anti-GBM treatments. Although vascularization is now widely recognized to be of importance in GBM modeling, the influence of blood components and blood cell population are mostly neglected. The analysis of the composition of the secretome of GBM could be helpful for a more accurate diagnosis of the disease. Adverse effects of drugs or xenobiotics to the brain vascular system are still largely misunderstood. The toxicological field is just beginning to yield the benefits of 3D engineered in vitro models and on the threshold of further extensive studies using these innovative technologies for the improvement of biosafety and bioavailability of novel neuropathology treatments.Brain microvasculature modeling is still particularly challenging in tissue engineering, as it needs to take into account the unique structure of the BBB, the highly specific brain microenvironment, and intercellular communication. The latest 3D MP and AF wrote and edited the manuscript. MM edited and oversaw the completion of the review. All authors have seen and approved the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


We describe the case of a 45-year-old woman with an unusual presentation of metastatic ovarian cancer. The patient presented to the oncological clinic with a three-week history of skin rash on the right breast. She underwent a chest and abdomen CT scan, which showed skin thickening of the right breast, right pleural effusion and bilateral cystic ovarian masses. Biopsy of a left ovarian lesion by diagnostic laparoscopy revealed the presence of ovarian serous carcinoma. Biopsy of the breast skin lesion revealed the presence of carcinomatous lymphangitis and immunohistochemistry documented the ovarian origin.


Rapid development of advanced gastrointestinal endoscopic techniques contributed to the appearance of new biomedical materials including polymers, which are used for the production of different types of endoprostheses. Endotherapy (ET) of postinflammatory pancreatic and peripancreatic fluid collections (PPFCs) with the use of lumen-apposing metal stent (LAMS) is an effective method of treatment. This paper describes the high efficacy of ET and its potential complications, which are mostly related to the design of the LAMS used. The high efficacy of LAMS in the transmural drainage of PPFCs is associated with lower safety of treatment. Complications of ET presented in the manuscript are mainly related to endoprosthesis' construction. This paper presents possible directions of development in the field of transmural LAMSs, which in the future may contribute to the invention of an innovative type of LAMS based on new biomedical technologies. Possibly, subsequent novel endoprosthesis projects, based on the above results, will be able to meet the current needs and requirements associated with endoscopic transmural drainage procedures in cases of postinflammatory PPFCs. The ultimate goal is to improve safety of minimally invasive techniques for treatment of the local consequences of pancreatitis. Acute pancreatitis (AP) of moderate and severe clinical course is associated with high risk of local complications and organ failure leading to increased mortality –4. PancrEndoscopic transmural drainage consists in creating a fistula between the lumen of the PPFC and gastrointestinal tract to allow for outflow of the content from the PPFC into the gastrointestinal tract , 15, 16.Development of advanced endoscopic techniques has led to rapid advancements in biomedical materials, including polymers for manufacturing endotherapeutic devices. Currently, there is a wide variety of transmural endoprostheses of different sizes, shapes, and designs for endoscopic treatment of postinflammatory PPFCs . These eHowever, the role of LAMSs in transmural drainage remains unclear , 17–23. In addition, the authors present an endoscopist's input regarding an ideal transmural endoprosthesis to improve the outcomes of endotherapy in postinflammatory PPFCs.Prospective analysis of treatment outcomes in patients with postinflammatory PPFCs in late phase (>4 weeks) of pancreatitis, who received endoscopic treatment at the Department of General, Gastroenterological, and Oncological Surgery, Ludwik Rydygier Collegium Medicum, in Bydgoszcz, Nicolaus Copernicus University, in Toruń from 2018 to 2021.The study was approved by the Ethics Committee at the Collegium Medicum of the Nicolaus Copernicus University and was conducted in accordance with the Declaration of Helsinki. All patients provided informed consent for endoscopic procedures.The diagnosis of pancreatitis, the criteria of clinical and morphological categorization, and all the definitions of local and systemic complications were based on the 2012 revised Atlanta classification . The staAll patients with clinical symptoms of PPFCs due to acute or chronic pancreatitis were enrolled. The patients underwent endoscopic drainage procedures. Qualification for endoscopic treatment was based on the clinical picture and imaging results, primarily abdominal contrast-enhanced computed tomography (CECT). The start of endoscopic treatment was postponed until the collection became encysted at the latest. If it was necrotic, the necrotic material collected within the cavity became liquified and a WOPN was formed, which occurred four weeks from the onset of the disease and was determined on the basis of imaging examinations of the abdominal cavity.Patients with PPFCs that were not a consequence of pancreatic inflammatory disease were excluded from the study. The study also excluded patients with postinflammatory PPFCs without clinical symptoms and those who had undergone surgery in the pancreatic region. Patients who had undergone interventional treatment in the early phase (<4 weeks) of AP were also excluded.In patients with symptomatic PPFCs in the late phase of pancreatitis, transmural drainage using the single transluminal gateway technique (SGT) was performed if endoscopic ultrasound revealed that the distance between the wall of the collection and the gastrointestinal wall did not exceed 30 mm. In patients with sterile pancreatic pseudocysts, the method of choice was passive transmural drainage. In patients with infected pancreatic pseudocysts or WOPN (both sterile and infected), the method of intervention was active transmural drainage.In the event that drainage with the single transluminal gateway technique (SGT) was ineffective and the fluid collection spreads beyond the lesser sac, multiple transluminal gateway technique (MTGT) was used. This technique has also been used in cases of multilocular postinflammatory PPFCs. If the necrotic areas were infected or transmural drainage was unsuccessful for WOPN patients, direct endoscopic necrosectomy was performed.If endoscopic techniques with transmural access were ineffective, additional access to the collection cavity was created using percutaneous drainage  or transpapillary drainage . Endoscopic retrograde pancreatography (ERP) revealed communication between the main pancreatic duct (MPD) and the PPFC cavity.Endoscopic procedures were performed under general anesthesia with tracheal intubation. All patients provided informed consent for this procedure. All were performed by a single endoscopist, and the procedure entailed carbon dioxide insufflation and use of a linear echoendoscope , duodenoscope , and gastroscope . Before the procedure, all patients received prophylactic antibiotic treatment (ciprofloxacin or ceftriaxone). Samples of the material contained in the PPFC were collected for microbiological, cytological, and laboratory analyses.Placement of the pancreaticogastric or pancreaticoduodenal anastomosis in the form of transmural cystostomy was performed under EUS guidance. The anastomosis between the gastrointestinal lumen and the collection cavity was created with a 10 Fr cystotome  and then dilated with a high-pressure balloon with a diameter of up to 15 mm (Cook Endoscopy or Boston Scientific). Through the stomy, a transmural metal endoprosthesis (LAMS) was inserted, measuring 16 mm in diameter and 20 mm, 30 mm, or 40 mm in length  Figures  and 8. FIn patients with additional transmural stomy created between the collection and lumen of the gastrointestinal tract, the placement of the anastomosis was also decided under EUS guidance. The transmural cystostomy was created with a 10 Fr cystostome  and expanded with a high-pressure balloon with a diameter of up to 15 mm . Next, a metal endoprosthesis (LAMS) with a diameter of 16 mm and length of 30 mm or 40 mm  was inserted transmurally. Depending on the type of drainage, a 7 Fr or 8.5 Fr nasal (Wilson-Cook) and/or 7 Fr or 8 Fr double-pigtail stent (Wilson Cook) drain was inserted through the endoprosthesis and into the collection lumen.Direct endoscopic necrosectomy procedures, which mechanically remove necrotic tissue, were performed in WOPN patients with no clinical improvement despite the drainage treatment or even if the necrotic collections became infected. The first stage of DEN involved removing the nasal drain. Through the transmural stomy with the LAMS inside, a gastroscope was introduced into the necrotic area. The necrotic collection cavity was subsequently flushed multiple times with saline solution, and the washings were removed by suction. A 15–20 mm extraction balloon (Cook Endoscopy) and Dormia basket (Cook Endoscopy or Olympus) were used to remove necrotic tissue under direct endoscopic image guidance. This procedure was repeated several times. Upon completion, the nasal drain and/or double pigtail plastic stents were reinserted transmurally.When active transmural drainage was used, the PPFC was flushed with saline (60–200 mL) through the nasal drain every 2 hours during the first 48 hours of the postoperative period and every 4 to 6 hours on the following days. If the patient's clinical symptoms suggested PPFC infection, the antibiotic therapy was prolonged or the contents of the collection were cultured again with antibiotic susceptibility testing.During active transmural drainage, the size of the fluid collection was measured every seven days via abdominal ultrasound. Abdominal CECT was used to confirm complete regression of the fluid collection or in cases where the patient's clinical condition deteriorated despite ongoing treatment. Active drainage was discontinued once clinical success could be established, while the patients were still on passive transmural drainage. After four weeks, an endoscopic procedure was performed during subsequent hospitalization and the passive transmural drainage was either continued  or discontinued . The decision to continue passive transmural drainage was made depending on the fluid collection size and the presence of any disruption in the MPD, as revealed during ERP. If the PPFC persisted in residual form (–30–40 mm) or recurred (>40 mm), passive endoscopic drainage was continued and the transmural endoprostheses were replaced for another four weeks. In cases of complete PPFC regression, an endoscopic procedure was performed to remove the transmural endoprostheses and passive endoscopic drainage was completed.Technical success was defined as successful placement under endoscopic and radiologic image guidance of the transmural stent with its distal and proximal ends located in the PPFC cavity and lumen of the gastrointestinal tract (stomach or duodenum), respectively. A procedure was confirmed to be technically successful if the contrast agent administered was flowing freely from the PPFC through the transmural stent without leaking out of the gastrointestinal tract or the stent.Clinical success was defined as resolution of complaints associated with the presence of the PPFC and complete regression of the collection or its diameter decreasing to <40 mm in imaging tests.Long-term success was defined as the absence of complaints and complete PPFC regression or its size decreasing to <40 mm during follow-up after the end of the endoscopic drainage.Recurrence of fluid collection was understood as a collection size of >40 mm or reappearance of symptoms during follow-up.Transmural stent dislocation was defined as the spontaneous migration of the transmural stent away from the anastomosis between the gastrointestinal lumen and PPFC cavity.Early dislocation of the transmural stent was established if dislocation occurred within the first seven days following the procedure of endoscopic transmural drainage.Late dislocation of the transmural stent was established if dislocation occurred more than seven days after the procedure.Proximal stent dislocation was defined as migration of the transmural endoprosthesis from the anastomosis into PPFC lumen, where both flanges of the stent were inside the collection cavity and away from the gastrointestinal wall.Distal stent dislocation was defined as migration of the transmural endoprosthesis from the anastomosis into the lumen of the gastrointestinal tract, where both flanges of the stent were inside the gastrointestinal lumen.http://statistica.io). Quantitative variables are characterized using arithmetic means, standard deviation, median, and minimum and maximum values (range). Qualitative variables are presented as numbers and percentages.All statistical calculations were conducted using the statistical software TIBCO Software Inc. (2017). Statistica software , version 13, was also used  years) were diagnosed with WOPN and 69  years) with pancreatic pseudocysts. The mean time from the onset of pancreatitis to the start of endotherapy (ET) was 76 (29–411) days. Chronic pancreatitis was diagnosed in 72 patients (28.02%). Detailed patient characteristics are presented in Escherichia coli, Klebsiella pneumoniae, Enterococcus faecalis, and Staphylococcus epidermidis. The remaining indications for endoscopic treatment are shown in An infection diagnosed on the basis of a positive culture of the PPFC contents was present in 115 patients with WOPN and in 42 patients with pancreatic pseudocysts. In both groups, the most common bacterial pathogens isolated from the fluid sample were All 257 patients underwent endoscopic transmural drainage of postinflammatory PPFCs . Twenty-seven patients with sterile pancreatic pseudocysts underwent passive transmural drainage initially. Active transmural drainage was performed in 230 patients (188 patients with WOPN and 42 patients with infected pancreatic pseudocysts). Additional active transpapillary drainage was performed in 11 patients  and an aSingle transluminal gateway techniques Figures  were appActive endoscopic drainage took an average of 13.34 (5–82) days. The average duration of passive transmural drainage was 84 (25–281) days. The mean number of endoscopic procedures was 8.61 (2–28). During the endoscopic treatment of the 257 patients with PPFCs, 942 LAMS were used.Complications during endoscopic transmural drainage were observed in 34 patients (13.23%). Of these, a vast majority were stent-related complications, constituting 32 of the complicated cases. Among the 34 patients who experienced endotherapy complications, 8 required surgical treatment. Detailed information on the complications is presented in The most common complication of endoscopic treatment was bleeding into the upper gastrointestinal tract, which was observed in 20 patients. For all cases, the cause was bleeding from the PPFC through transmural cystostomy into the gastrointestinal lumen .Hemospray, Cook Endoscopy) sprayed into the collection cavity was effective for managing bleeding in 5 patients. Another 5 patients required endovascular treatment with embolization of the perforated vessel (4 cases) or insertion of a stent graft to bypass the site of vascular rupture (1 case)  drainage was used to treat the pancreatic fluid collection. Among the 5 patients who underwent surgical treatment for early transmural stent dislocation, 3 required a laparotomy Figures  and 2 unPPFC perforation with fluid leakage from the collection cavity into the retroperitoneal space was found in 2 patients. One of these patients required surgical treatment; laparotomy was performed with drainage and rinsing of the retroperitoneum. The other patient underwent successful percutaneous drainage of the retroperitoneal space without the need to resort to surgical treatment.Five of the 34 complicated cases developed late dislocation of the transmural stent. Two of these patients were diagnosed with distal dislocation of the stent into the gastrointestinal lumen. The remaining three patients had proximal dislocation of the transmural stent into the collection cavity. The average time from the procedure to the diagnosis of late dislocation was 17 (10–27) days. In all dislocation cases, an endoscopic procedure was performed wherein the dislodged stent was grasped with rat tooth forceps and pulled outside Figures .Technical success of the transmural drainage procedure was achieved in 255 patients (99.22%). Clinical success was achieved in 242 patients (94.16%).Mortality during ET was observed in 8 patients (3.11%) and was not associated with ongoing endoscopic treatment. All fatal cases reported were caused by multiple organ failure during the course of severe acute necrotizing pancreatitis.During the follow-up period, which lasted an average of 213 (32–1034) days, long-term success of PPFC ET was achieved in 221 patients (85.99%). PPFC recurrence was reported in 17 patients during follow-up. Of these, 15 patients underwent successful endoscopic treatment for recurrent fluid collection. In two patients, the recurrent PPFC necessitated surgical treatment.The choice of drainage technique in patients with postinflammatory PPFCs should rely primarily on experience of the treating medical center , 26–33. Traditionally, endoscopic transmural drainage of postinflammatory PPFCs has been performed using plastic (teflon or polyethylene) double-pigtail stents , 15–18. As a result of advancements in biomedical materials, SEMSs were introduced to the market , 34–41. With this, only the fully covered type can find application in transmural drainage of postinflammatory PPFCs, where the SEMS must be removed upon treatment completion , 19–23. The two most common and most serious groups of complications associated with the endoscopic treatment of PPFCs are gastrointestinal bleeding  and perfWith regard to gastrointestinal bleeding during transmural drainage of postinflammatory PPFCs, great progress in reducing the incidence of complications has been achieved with the advent of EUS techniques , 17. EUSThe application of new polymers in manufacturing transmural stents in the form of additional layers of coating to the distal flange of the LAMS will most certainly limit the risk of PPFC cavity bleeding during transmural drainage procedures. This will make it less likely for the distal flange of the LAMS to injure the back wall of the PPFC, and it will no longer be necessary to insert a plastic double-pigtail stent through the lumen of the LAMS. The thick polymer coating of the most protruding part of the distal flange will then take over the function hitherto performed by the additional plastic stent, which can lower the costs of endoscopic treatment of PPFCs.Another major complication of transmural drainage with LAMS is gastrointestinal tract perforation due to transmural stent dislocation that migrates outside of the transmural anastomosis –45. GastTreating transmural stent dislocation should primarily depend on the patient's clinical condition. In stable patients with an early transmural stent dislocation and air leaking out of the gastrointestinal lumen, as revealed by imaging, endoscopic treatment can be attempted to adjust the position of the dislodged stent or add another stent using the stent-in-stent technique. If this strategy is successful, it is also necessary to remove air from the peritoneal cavity through a percutaneous incision. Endoscopic treatment of early dislocations of LAMS, despite favorable short-term outcomes, usually prove ineffective on long-term follow-up, thus leaving surgical treatment as the method of choice. This paper describes an effective method of surgical treatment for early dislocation of the LAMS, consisting of suturing the perforated site  within the upper gastrointestinal tract and removing the dislodged transmural stent through laparotomy or, preferably, through laparoscopic access. The surgery also involves percutaneous drainage  of the PPFC. Subsequently, in the postoperative period, while the external drainage is still ongoing, an endoscopic procedure is performed, whereby internal drainage  of the PPFC is provided. Upon internal drainage completion, the external drainage was removed. This is how external drainage is replaced with the PPFC internal drainage.In cases of late transmural stent dislocation occurring more than a week after the procedure, endotherapy is generally an effective method of treatment. Proximal stent migration occurs when the transmural stent migrates into the PPFC lumen. Endoscopic treatment of late proximal dislocation of the transmural stent involves inserting another transmural stent through the transmural cystostomy or creating another cystostomy between the gastrointestinal lumen and the PPFC cavity. Through the transmural endoprosthesis, an endoscope is inserted into the PPFC under the guidance of endoscopic imaging. Different types of endoscopic tools are used to capture and remove the dislodged stent. In cases of late distal dislocation of the transmural LAMS where the stent migrates into the gastrointestinal lumen and if the dislodged stent is located within the upper gastrointestinal tract, it can still be removed with the use of endoscopic techniques. However, if the dislodged stent has migrated further down the gastrointestinal tract and beyond the duodenojejunal flexure (ligament of Treitz), the patient is usually monitored until the stent is spontaneously passed along the entire gastrointestinal tract without any complications. If these strategies fail, surgical treatment remains the method of choice.As one follows the continuous dynamic development of biomedical technologies, it can be presumed that as the design of transmural stents evolves towards a larger diameter and size of both flanges and their improved shape, it will become possible to limit the risk of early and late dislocations of transmural LAMS in terms of both distal and proximal migrations. Moreover, a sufficiently larger lumen diameter of the LAMS prevents it from being obstructed by necrotic tissues.According to the guidelines for endotherapy of postinflammatory PPFCs, transmural LAMS should be either replaced or removed after 8–12 weeks , 36–41. This paper addresses the challenges and issues faced by endoscopists performing transmural drainage using LAMS. From the endoscopist's perspective, a major challenge in transmural drainage of PPFCs is often the right placement of the stent. This is a crucial stage in determining the technical success of the procedure. Once the transmural cystostomy is performed and the guidewire is inserted into the PPFC, the transmural stent is introduced. Considering the challenging anatomical conditions and rigid nature of the stent delivery system used to introduce the unexpanded LAMS, this stage requires particular caution while expanding the stent. Failure of any kind has the potential to cause early dislocation of the stent during the endoscopic procedure, which can lead to gastrointestinal perforation. At this point, this depends on the experience and skill of the endoscopist. While the construction and technical features of the stent delivery system can be expected to improve, the difficult anatomical environment will not. In particular, PPFCs are located away from the gastrointestinal wall, which do not form a discernible bulge on the gastric or duodenal wall and are situated within the distal part of the pancreatic body or within the tail, where transmural access can usually be obtained from the subcardiac region of the stomach, often with endoscopic inversion. A major convenience with regard to improving the quality and safety of endoscopic transmural drainage with LAMS is the controlled release system used in certain types of SEMS, which allows for accurate and controlled placement of the transmural stent in the desired location. This solution limits the risk of transmural stent dislocation and consequently reduces the potential for gastrointestinal perforations and leaks within the pancreaticogastric or pancreaticoduodenal anastomosis. Despite these benefits, controlled release systems have not yet been featured in LAMS for transmural drainage.This paper discussed the high efficacy of ET and its potential complications, which are mostly related to the design of the LAMS used. The high efficacy of LAMS in the transmural drainage of PPFCs is associated with lower treatment safety. Most ET complications respond to conservative or minimally invasive treatments, including endoscopic techniques. Surgical treatment of this type of complication remains the method of choice if other treatment options fail.This paper discusses possible directions of development in the field of transmural LAMSs. It may also be helpful in addressing the possible expectations of the interventional endoscopist towards stent designers and manufacturers. High hopes for improving the quality of endoscopic equipment are placed in the development of new technologies from biomedical materials, including polymers, equipment for the production of equipment. Possibly, subsequent novel endoprosthesis projects, based on the above results, will be able to meet the current needs and requirements associated with endoscopic endoscopic transmural drainage procedures in cases of postinflammatory PPFCs. The ultimate goal is to improve the safety of minimally invasive techniques for the treatment of the local consequences of pancreatitis. Hopefully, our findings will contribute to development of novel and original transmural LAMS designs.


This cross-sectional study compares the number of encounters at the Massachusetts Child Psychiatry Access Program, patient characteristics, and mental health diagnoses before vs during the COVID-19 pandemic. Published data about the mental health effects of the COVID-19 pandemic do not capture the substantial number of youths who do not visit the hospital. Thus, we examined data from the Massachusetts Child Psychiatry Access Program (MCPAP), established in 2004 to aid PCCs in providing psychiatric treatment through consultation and referral services.5COVID-19 pandemic–related social isolation, school closures, and anxiety about the future have been negatively associated with youths’ mental health.STROBE) reporting guideline.For this cross-sectional study, we collected data from the MCPAP database for counts of unique patient telephone and in-person encounters during fiscal years (FYs) 2019 through 2021. The UMass Chan Medical School institutional review board indicated that oversight and informed consent was not required because the study team did not access private identifiable information. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology  and during the pandemic (March and April in 2021) by sex, type of insurance, and patient age. These months were chosen for consistency relative to the timing of the pandemic and to minimize seasonal differences. The mean number of monthly encounters by mental health diagnosis was compared between periods before and during the pandemic using descriptive data (means and percentage change). P < .05 using a 2-tailed test was considered statistically significant. Analyses were conducted using SAS, version 9.4 .The number of monthly encounters in FY 2021 was compared with those in FY 2019 and FY 2020 using a Mann-Whitney This study included 2515 unique patients with encounters at the MCPAP before the COVID-19 pandemic and 1700 unique patients with encounters during the pandemic. Patient characteristics are presented in the U test indicated that the number of monthly encounters was greater in FY 2021  compared with FY 2019  and FY 2020 .The 6 Data from March and April of 2021 showed increased health care use compared with March and April 2018 and 2019, particularly consultations for anxiety and depression, aligning with published data.1 Of note, the diagnosis with the greatest increase in MCPAP consultations was autism spectrum disorder. We hypothesize that decreased availability of in-home applied behavioral analysis and in-person special education was associated with disruption and stress for youths and families who depend on them. Girls and older adolescents were more likely to present to their PCCs, but the structure of our data did not allow us to explore interactions between sex, age, and type of presenting condition, limiting the interpretation of the results.The decrease in MCPAP use during the early months of the COVID-19 pandemic found in this study corresponds with the overall initial decrease in health care use not directly associated with COVID-19.Our data suggest a trend of increasing need for pediatric behavioral health services and treatment on an outpatient basis. Although the data cannot suggest a cause for increased needs among youths, in our study, the number of youths presenting to their PCCs with mental health concerns and the complexity of presentation increased during the pandemic compared with before the pandemic. This finding suggests a need for increasing capacity to meet demand.


The soma, dendrites and axon of neurons may display calcium-dependent release of transmitters and peptides. Such release is named extrasynaptic for occurring in absence of synaptic structures. This review describes the cooperative actions of three calcium sources on somatic exocytosis. Emphasis is given to the somatic release of serotonin by the classical leech Retzius neuron, which has allowed detailed studies on the fine steps from excitation to exocytosis. Trains of action potentials induce transmembrane calcium entry through L-type channels. For action potential frequencies above 5 Hz, summation of calcium transients on individual action potentials activates the second calcium source: ryanodine receptors produce calcium-induced calcium release. The resulting calcium tsunami activates mitochondrial ATP synthesis to fuel transport of vesicles to the plasma membrane. Serotonin that is released maintains a large-scale exocytosis by activating the third calcium source: serotonin autoreceptors coupled to phospholipase C promote IP3 production. Activated IP3 receptors in peripheral endoplasmic reticulum release calcium that promotes vesicle fusion. The Swiss-clock workings of the machinery for somatic exocytosis has a striking disadvantage. The essential calcium-releasing endoplasmic reticulum near the plasma membrane hinders the vesicle transport, drastically reducing the thermodynamic efficiency of the ATP expenses and elevating the energy cost of release. Streams of action potentials or long depolarizations may evoke calcium-dependent exocytosis of transmitters and peptides from the soma, dendrites and axon of neurons in the absence of pre- and postsynaptic structures ,5,6,7,8.All peptides and most classical low molecular weight transmitters have been shown to be released extrasynaptically from vesicles, either clear or often dense-core vesicles that rest distantly from the plasma membrane . TherefoThis review summarizes experimental evidence about the ways by which calcium flow through transmembrane and intracellular channels contributes in an orderly manner to induce vesicle transport and a large-scale exocytosis that lasts for hundreds of seconds. The backbone for the paper is experiments made on the soma of the classical large serotonergic Retzius neuron of the leech CNS, which allows direct experimentation to analyze the sequence of fine steps that couple electrical activity with exocytosis . Data suUltrastructural analysis of the soma of Retzius neurons under different stimulation frequencies permits an initial understanding of the role of electrical stimulation and calcium on somatic exocytosis. The electron micrographs in The first source of calcium for somatic exocytosis in Retzius neurons is the transmembrane flow through L-type (CaV1) channels ,33. L-tyEvidence on the presence of L-type channels in the plasma membrane of the soma of Retzius neurons came first from loose patch clamp recordings of currents from small areas of plasma membrane . Figure Somatic exocytosis of serotonin can be evoked in Retzius cells in a frequency-dependent manner by trains of action potentials but not by individual action potentials ,40. ExocBlockade of L-type channels through the incubation of neurons with nimodipine abolishes exocytosis upon 20 Hz stimulation without affecting the constitutive exocytosis A 32,40],4032,40]Essential to understanding the translation of the firing frequency into the amount of somatic exocytosis was to image the calcium elevations from the fluorescence of the high affinity Fluo calcium sensors upon different stimulation frequencies. Such measurements showed that the calcium transient on each individual action potential experienced frequency-dependent summation . Figure Summarizing these observations, 20 Hz stimulation produces summation of the transmembrane calcium elevation that follows each action potential. Activation of calcium-induced calcium release, the second pool of calcium, rapidly increases the concentration of the calcium wave that invades the soma. A third calcium pool in the periphery correlates with the duration of exocytosis.The possibility of calcium-induced calcium release being the second calcium pool activated by 20 Hz stimulation was explored by pharmacological manipulations of L-type calcium channels and the well-known ryanodine receptors in endoplasmic reticulum, which respond to cytoplasmic calcium by releasing more calcium ,46,47.As expected, blockade of L-type channels with nimodipine nearly abolished the fast calcium transient on 20 Hz stimulation . A seconThe intriguing observation that the fast calcium transient decays long before the arrival of vesicles at the plasma membrane along with that of vesicles remaining at resting positions when transmembrane calcium entry is abolished by extracellular magnesium, allowed us to put forward a new hypothesis: the primary role of the calcium tsunami is to set in motion the transport of vesicle clusters to the plasma membrane. By imaging fluorescence mitochondrial specific calcium sensor Rhod-2, we confirmed that the number of transported vesicle clusters depends sigmoidally on the stimulation frequency through the amount of calcium that invades the mitochondria . Then we found that blocking calcium entry to the mitochondria prevents exocytosis. Therefore, newly synthesized ATP seems to provide the energy for kinesin-tubulin and actin myosin motor systems to carry vesicle clusters to the plasma membrane. Such transport was studied by using thermodynamic theory applied to the kinetics of the exocytosis, seen as the development of the fluorescent FM1-43 spots. The transport place at 15–90 nm/sec velocity, depending primarily on the vesicle cargo .A comparison of the kinetics of the calcium signals and exocytosis showed another striking result: the calcium signal that maintains the large-scale exocytosis is the peripheral transient. The kinetics of exocytosis showed that the lag to the onset of exocytosis reflects the distance and velocity of the vesicle cluster transport; the dynamic interval (a and a’ in It is common that exocytosis from a vesicle cluster is followed by exocytosis from a second vesicle cluster that arrives at the same membrane spot, thus producing a second florescence increase (a’ and c’ in The immediate possibility that the third pool of calcium enters across the plasma membrane through voltage gated channels, ionotropic receptors, or through constitutive or capacitive channels which may evoke release in gland cells ,50 was cIn simultaneous optical recordings of calcium and exocytosis, both signals are abolished by the serotonin antagonist methisergide, which has higher specificity for 5-HT2 receptors C. ActivaThe mechanism for extrasynaptic exocytosis of serotonin by Retzius neurons is resumed in The Swiss-clock precision of the machinery for somatic exocytosis imposes a high energy cost to the transport process. The amplified electron micrograph in The ATP cost per vesicle and the thermodynamic efficiency of the vesicle transport have been calculated by applying the thermodynamic theory to the kinetics of exocytosis, which, as mentioned before, reports on the number of vesicles in the cluster, their travelling distance and velocity ,61. InteThe barrier imposed by the actin cortex to vesicle transport at rest turns into a permissive pathway in response to stimulation. Such an effect shown first in endocrine cells ,63 appeaThe ATP cost per vesicle and the thermodynamic efficiency of the ATP expenses are highly dependent on the traveling distance of the vesicles ,61. The It is to be noted that the 6.4% largest thermodynamic efficiency in Somatic exocytosis by Retzius neurons is regulated by a sequential activation of three calcium sources. The first two sources cooperate to regulate the amount of transmitter transported to the plasma membrane; the third source activates vesicle fusion.Increases in the frequency of electrical activity allow for the summation of transmembrane calcium transients generated upon activation of L-type calcium channels. As the stimulation frequency increases, summation increases the free calcium concentration and activates a second calcium source: calcium-induced calcium release.Calcium-induced calcium release increases the amplitude of the intracellular calcium transient. A resulting calcium tsunami invades the mitochondria and makes them produce ATP for the vesicle transport to the plasma membrane. The amplitude of the calcium transient in the mitochondria determines the number of vesicles transported and fused.Serotonin that is released maintains a large-scale exocytosis for hundreds of seconds through a third calcium source: the activation of 5-HT2 receptors coupled to phospholipase C and production of IP3 produces calcium release from endoplasmic reticulum adjacent to the plasma membrane.The calcium-releasing endoplasmic reticulum and the actin cortex generate obstacles to the transport pathway of vesicles. The resulting friction forces reduce the thermodynamic efficiency of the ATP usage, adding energy cost to somatic exocytosis.


The neural regulation of glucose homeostasis in normal and challenged conditions involves the modulation of pancreatic islet-cell function. Compromising the pancreas innervation causes islet autoimmunity in type 1 diabetes and islet cell dysfunction in type 2 diabetes. However, despite the richly innervated nature of the pancreas, islet innervation remains ill-defined. Here, we review the neuroanatomical and humoral basis of the cross-talk between the endocrine pancreas and autonomic and sensory neurons. Identifying the neurocircuitry and neurochemistry of the neuro-insular network would provide clues to neuromodulation-based approaches for the prevention and treatment of diabetes and obesity. Both systems receive enriched autonomic innervations  are either small-diameter myelinated Aδ or unmyelinated C fibers. The afferent fibers travel with efferent fibers, contribute to the celiac plexus, and continue to follow blood vessels to reach the pancreas . Tracingvia activation of TRPV1, which is expressed by most unmyelinated sensory neurons and some small-diameter myelinated sensory neurons  at thoracic 6 (T6) – lumbar 2 (L2) segmental levels of the spinal cord. These afferent fibers transmit information from the pancreas to the spinal cord through the splanchnic nerves and celiac plexus and terminate monosynaptically in lamina I and IV in the dorsal horn at the same spinal segment , are involved in sensing both chemical and mechanical signals , sensory information from the aortic body and carotid body through the glossopharyngeal nerve, sensory information from the taste organs through the facial nerve, sensory information from the auditory organs through the vagus nerve, and modulatory information from the upper brain centers  and the area postrema receiving visceral vagal afferents from the pancreas  located in the pancreas  mediated vago-vagal reflex  has been studied in a variety of mammals. Two types of the neuro-insular complex have been proposed: (I) a gathering of islet cells and ganglionic cells; and (II) bundles of nerve fibers in close contact with islet cells  and oxytocin. Magnocellular AVP- and oxytocin-containing neurons are mainly located in the paraventricular nucleus and supraoptic nuclei of the hypothalamus. A few accessory cells can also be found in the medial and lateral hypothalamus  and the central nervous system . Similar problems are likely to also occur with the use of neurotropic viral tracers (Streefland et al., The endocrine and exocrine functions of the pancreas are regulated tightly by the complex and integrated responses of the functional nervous circuits. Sensory fibers of both parasympathetic and sympathetic pathways terminate monosynaptically in the vagus nerve centers and the dorsal horn neurons at T6-L2 segmental levels of the spinal cord, respectively. Medullary neurons in the NTS, the DMV, and the area postrema form a functional spino-medullary circuit for somato-autonomic reflexes to modulate both the endocrine and exocrine functions in the pancreas polysynaptically. The reticular activating system, mesencephalic homeostatic centers, the hypothalamic autonomic nervous system, thalamocortical circuits, and interoceptive centers play modulatory roles in the regulation of pancreatic functions.The first draft of the manuscript was written by BL and all authors contributed to editorial changes in the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.