Overt thyroid dysfunction is an accepted cause of female infertility. Its milder form, subclinical hypothyroidism have also been implicated as a contributing factor to disturbed reproductive function.To determine the contribution of subclinical hypothyroidism (SCH) to the burden of infertility.This is a cross sectional, comparative study of One hundred and twenty women with primary or secondaryinfertility who presented for evaluation at gynaecological clinic and controls which are clients that came to access Family planning services.The prevalence of infertility among gynaecological patients seen in the clinic was 38.8% (192/495). The prevalence of SCH among the studied infertile women was 11.7% (7/60) compared with 3.3% (2/60) of the control group (p=0.222). The commonest type of infertility was secondary, 76.7% (46/60). All thestudied infertile women with SCH presented with secondary infertility. There was an observed statistically significant difference in the mean serum TSH (3.19±4.38mIU /L vs 1.60±1.22mIU /L) and FT3, FT4 (0.29±0.074ng/dl vs 0.95±0.16ng/dl and 0.33±0.071ng/dl vs 1.09±0.19ng/dl respectively)Subclinical hypothyroidism was found to be higher among infertile women but this finding was not statistically significant, therefore, the routine screening for SCH among infertile women might be unnecessary In Africa, children are the fabric of any society, without which no significant social and economic progress is considered worthwhile.4Hypothyroidism is a very common but subtle endocrinological problem with a variety of changes in reproductive functions including delayed onset of puberty, menstrual disorders, anovulatory cycles, infertility and reproductive wastage when pregnancy is achieved.10Subclinical hypothyroidism has long been considered as an infertility factor.The study was conducted in an urban area at the gynaecologicaland family planning clinics of the Department of Obstetrics and Gynaecology of Olabisi Onabanjo University Teaching Hospital (OOUTH), Sagamu, Ogun state, South western, Nigeria. This is a public facility that serves as referral center to many hospitals in the state and neighbouring states.Gynaecological services are provided for our women by nurses, resident doctors undergoing specialist gynaecological training and consultant gynaecologist. The assays of the serum TSH, free triiodothyronine and free thyroxine level were done in conjunction with the Chemical pathologist at the laboratory service department of the hospital.The study population consists of women of reproductive age (15–49 years) who had been married for at least one year with no obvious history of thyroid disease presenting with ovulatory factor infertility and parous (fertile) women at Family Planning clinic without history of thyroid disease as controls at OOUTH, Sagamu.This was a comparative  study of consecutive samples of women of reproductive age withovulatory factor infertility as cases while the control group were parous (fertile) women attending family planning clinic. The controls were matched with age of the infertile population. Women with Overt hypothyroidism, overt hyperthyroidism, history of previous thyroid surgery, history of previous or recent treatment with thyroid medication and women with any obvious cause of infertility other than anovulation were excluded from the study.Overt hypothyroidism is seen as an increase in serum TSH levels (> 20 mIU/L) and decrease in serum free T4 concentrations while subclinical hypothyroidism is characterized by normal serum free thyroxine concentration with elevated serum TSH concentrations ranging between 4.5 mIU/L and 20 mIU/L.12Data collected include socio-demographic data, duration of marriage and infertility, history of any previous pregnancies and outcome, menstrual history and any possible abnormalities associated with it. In addition, serum was collected for the thyroid hormones assays and all these were recorded on the data collection form.Data were analyzed using Statistical Package for Social Science (SPSS) windows version 23. Demographic and baseline variables were summarized using descriptive statistics expressed as mean (standard deviation) or median (range) for continuous variables and percentages for categorical variables. Associations between variables were determined using independent t-test, Chi square and ANOVA as appropriate. The level of statistically significance was set at p-value <0.05.Ethical approvalfor the study was obtained from the Health Research Ethics Committee of Olabisi Onabanjo University Teaching Hospital, Sagamu (OOUTH/REC/038/2015). Consent was taken from the women and they were assured that non consent will not affect the level of management in any wayOne hundred and ninety-two infertile (ovulatory and other causes) women were seen among the 495 gynaecological cases that presented within the six months period of study giving a prevalence of 38.8%. All the women in both groups had some form of education with most of them having secondary and tertiary education (85% for cases and 80% for controls). Most of the participants were semi-skilled workers (50% for cases and 43.3% for controls) and there was no statistically significant difference in the job they engage in (P=0.838). There was an observed statistically significant difference in the Body mass index of both cases and controls (P=0.012), 28.3% versus 23.3% were overweight among cases and controls and 23.3% versus 11.7% were obese among cases and controls.The mean serum TSH, free T3 and free T4 among cases were 3.19±4.38 mIU/L, 0.29±0.074ng/dl and 0.95±0.16ng/dl respectively while among controls were 1.60±1.22 mIU/L, 0.33±0.071ng/dl and 1.09±0.19ng/dl respectively . Thus, tOut of the 60 cases recruited, 7(11.7%) were subclinical hypothyroid, 1(1.7%) was subclinical hyperthyroid and 52(86.6%) were euthyroid. . Out of Seven (15.2%) women with subclinical hypothyroidism were seen to present with secondary infertility while none presented with primary infertility. This observed difference was not statistically significant (P=0.100).Infertility is a common health problem with devastating psychosocial consequences on the affected couples especially in Africa.1The commonest type of infertility was secondary, seen in 76.7% (46/60) of participants while primary infertility was observed in 23.3% 14/60). The predominance of secondary infertility in this study is consistent with several studies in sub-Saharan Africa./60. The Hypothyroidism is the most common endocrinological problem affecting women who present with ovulatory dysfunction resulting in infertility.5The mean serum TSH, free T3 and free T4 levels were higher among the infertile women than the values in the fertile women. This trend was statistically significant (P= 0.008 for serum TSH) and (P= 0.001for serum T3 and T4). A similar trend was reported by Biradar et al,17The impact of hypothyroidism on ovulation and menstrual function is related to numerous interactions of the thyroid hormones with the female reproductive system, thus finally leading to infertility.Seven (15.2%) women with subclinical hypothyroidism presented with secondary infertility while none presented with primary infertility. The data shows that subclinical hypothyroidism was relatively more common in women with secondary infertility. This finding is not consistent with the study by Pushpagiri et al.Although the prevalence of subclinical hypothyroidism was found to be higher among infertile women compared to fertile women in OOUTH, Sagamu, this finding was not statistically significant (P=0.222). This might make routine assays of TSH in infertile women unnecessary.The study is limited by the small sample size and it was not multicentered, secondly, it was a cross-sectional study and you cannot objectively assert that SCH onset had a causal relationship with infertilitySubclinical hypothyroidism among infertile women evaluated was 11.7% compared to 3.3% in their fertile counterparts but this finding is not statistically significant therefore the routine screening for subclinical hypothyroidism among women being evaluated for infertility might be unnecessary. Further multicentre studies involving large numbers of infertile women is recommended in order to validate this finding.


Reproducibility of FM estimates was very high (R2 = 0.99) with high concordance (R2 = 0.99) and low absolute pure error (0.114 to 0.116 kg) and percent error (1.3 and 3%). Bland–Altman plots revealed no proportional bias with limits of agreement of 4.9 to −4.3 kg and 3.9 to −4.9 kg for females and males, respectively. A novel 2D model to estimate abdominal (lumbar 2–5) FM produced high correlations (R2 = 0.99) and concordance (R2 = 0.99) compared to DXA abdominal FM values. Conclusions: A smartphone camera trained with machine learning and automated processing of 2D lateral standing digital images is an objective and valid method to estimate FM and, with proof of concept, to determine abdominal FM. It can facilitate practical identification of the obesity phenotype in adults.Background: Obesity is chronic health problem. Screening for the obesity phenotype is limited by the availability of practical methods. Methods: We determined the reproducibility and accuracy of an automated machine-learning method using smartphone camera-enabled capture and analysis of single, two-dimensional (2D) standing lateral digital images to estimate fat mass (FM) compared to dual X-ray absorptiometry (DXA) in females and males. We also report the first model to predict abdominal FM using 2D digital images. Results: Gender-specific 2D estimates of FM were significantly correlated ( Obesity is a chronic multisystem disease that increases the risk of long-term medical complications, reduces life span, and increases health care costs. The World Health Organization estimated more than 650 million adults were obese in 2016, a value representing a three-fold worldwide increase since 1975 . Thus, i2, kg/m2) to stratify obesity-related health risks in a population. Although insensitive to inter-individual differences in fat and muscle [Methods to identify the obesity phenotype, designated as adiposity or excess body fat and abdominal fat accumulation, have limitations. Clinicians and epidemiologists classify body weight based on ranges of body mass index  and to derive a model of 2D digital photography (DP) with machine learning to estimate abdominal FM in adults.We recruited healthy adult Caucasian women and men aged 19 to 64 y by using advertisements and word of mouth to participate in this study, which was conducted at the Eubion Medical Center and Tor Vergata University, in Rome, Italy. Each prospective participant underwent a clinical examination and completed a health questionnaire to establish the absence of an unhealthy condition prior to participation. This study was approved by the Institutional Review Board of the University of Tor Vergata. Each participant provided written informed consent prior to participation in any testing.The patented operational principle of 2D DP is that the real value in metrics of each picture composing the surface of any digitally acquired image encased within a background can be computed by its occupation ratio within a digitally constructed virtual frame . The acqhttps://arxiv.org/abs/1506.01497) and a proprietary pre-trained model. This first step detects and extracts the human profile within the picture conditioned as a single, homogenous, white pixel (256-256-256) bitmap silhouette and black background  pixels. The percent of occupation of white compared to black pixels is utilized to compute a real pixel size. The original picture undergoes conditioning in a few seconds and is no longer available from the Cloud memory thus ensuring the anonymity of the individual. Detection begins with identification of landmarks at the eyes and the malleolus using Posenet (https://arxiv.org/abs/1803.08225). To construct the virtual frame, the pixel counts between lines set over the eyes and the malleolus form the frame’s vertical sides (y-axis), and the horizontal upper and lower limits (x-axis) are virtualized by a preset standard fraction of the vertical boundaries. The percent of occupation of white vs. black pixels is utilized to compute the real pixel  without dependence on distance and camera resolution. The detailed body detection and pixel size determination are achieved with DeepLabV3+ (https://arxiv.org/abs/1706.05587) and Cross-Domain Complementary Learning Using Pose for Multi-Person Part Segmentation (https://arxiv.org/abs/1907.05193). Proprietary equations are used to compute body and abdominal FM. Time from acquisition of digital image (photograph) to return of body composition estimate is approximately 12 s on a high speed WIFI connection.The operator uploads the original picture to the Cloud-based neural network educated by deep learning machine technology for automated intelligent conditioning with Python programming language, which removes the background using FasterRCNN  had standing lateral whole-body digital images taken with either iOS Apple smartphone (operating system 10 or newer) or Android (operating system 5 or more recent) with 5 megapixel minimum camera resolution. This relatively low resolution for contemporary higher resolution smart device cameras enables this method to be broadly usable.Volunteers came to the laboratory in the morning after an overnight fast wearing form-fitting clothing. Standing height and body weight were determined using standard medical equipment . Reference whole-body composition was determined with a GE Lunar iDXAncore sn 200278 using software version 14.10.022. In an independent sample of 63 adults , an experienced DXA technician identified lumbar vertebrae 2 through 5 (L2-5) in whole-body DXA scans and determined FM with appropriate software All participants were positioned supine and scanned within the dimensions of the DXA table.p < 0.05.Statistical analyses were performed using SYSTAT version 13  and version 19.0.3 . Descriptive data are expressed as mean ± SD. Statistical significance was set at We determined the reproducibility of conditioning of digital images from consecutive digital photographs of individuals, who were repositioned between acquisition of digital photographs, transformed into silhouettes, and then computed to the two FM values for each subject. Precision or technical error measurement (TEM) is reported as the average values (±SD), coefficient of variation, and mean differences (±SD).t-test. Bland–Altman plot was used to determine bias and limits of agreement (LOA) for the derived prediction model.Total body FM was estimated with a proprietary prediction model trained with DXA, exclusive of body weight as an independent variable, derived in an independent sample, and compared with DXA-determined reference FM measurements in groups stratified by gender. Strength of agreement between estimated and reference FM and abdominal FM was determined with the Linn concordance correlation coefficient . Absolutn = 12; males: n = 15). Estimated FM was similar for the consecutive tests for females  and males  with mean differences between tests not different (p = 0.82) than 0 . Coefficients of determination and concordance coefficients were high (p < 0.0001) for each group .Another sample of adults participated in the reproducibility trial  and male  groups. Within each gender group, predicted and measured FM values were significantly correlated  with concordance correlation coefficients of 0.95 and 0.91 for females and males (p < 0.0001), respectively. Absolute pure error (0.002 and 0.057 kg) and percent error (1.3 and 3%) were low in the female and male groups. The predicted and measured FM values were distributed linearly in the male and female samples with slopes similar to 1.0 and intercepts not different than 0  for females and males, respectively, with no significant (p = 0.2) trends or slopes relating difference values as a function of the average FM values. The limits of agreement  ranged from 4.9 to −4.3 kg and from 3.9 to −4.9 kg for females and males, respectively.The distribution of the differences between measured and predicted FM values as a function of increasing FM revealed no significant trends . The biaAn independent sample of healthy Caucasians adults participated in the pilot study to predict abdominal FM using 2D DP compared to DXA L2-5 scans . Note thp = 0.83) and males  with mean differences between tests not different (p = 0.83) than 0 . Coefficients of determination and concordance coefficients were high (p < 0.0001) for each group .Estimated abdominal FM values were similar for the consecutive tests with repositioning of each participant for females  and linearly related to DXA abdominal FM values (R2 = 0.95 and 0.88) with concordance (R2 = 0.97 and 0.94) and slopes similar to 1 and intercepts not different than 0  with high level of concordance between estimated and reference FM values (R2 = 0.91 to 0.95) and high precision (SEE = 2.3 to 2.4 kg). Absolute (0.002 to 0.057 kg) and percent errors (1.3 and 3%) between predicted and DXA-determined FM values were negligible. Predicted and reference FM values were similar , significantly correlated with high precision . Estimated and reference FM values were distributed similar to the line of identity. Examination of distribution of errors between paired 2D DP and DXA FM for individuals found minimal error or bias (0.5 and −0.3 kg) that was not affected by magnitude of FM  with LOA of 4.9 to −4.3 kg and 3.9 to −4.9 kg for females and males, respectively. These findings indicate very high reproducibility and agreement between predicted and reference FM values with lower technical error and higher sensitivity than previous studies of 2D DP model development and validation.The present study demonstrates the high precision, concordance, and accuracy of a single, standing lateral 2D digital image analyzed using automated machine learning to estimate FM in adults with a wide range of adiposity. Reproducibility of 2D DP FM estimates was very high , without proportional bias, and LOA of 5.6 to −5.7 and 5.6 to −5.4 kg for females and males, respectively. Fedewa et al. [2 = 0.99, SEE = 0.68 L) with no difference between mean digital and densitometric body volume values (p = 0.58). Estimates of body fatness (%fat), calculated with body volume estimates derived from 2D DP and UWW using a three-component body composition model, were significantly correlated (R2 = 0.93) with LOA of 4.13 to −3.98%. Similarly, FM values were highly correlated (R2 = 0.93) with LOA from 2.96 to −2.76 kg. Nana et al. [2 = 0.81 and RMSE = 2.8 and 2.9% for females and males, respectively) that were similar to DXA-determined %fat values. Bland–Altman plots revealed proportional bias with LOA of 5.6 to −5.8% and 5.6 to −5.4% for females and males, respectively.The application of 2D digital imaging for body shape and composition assessment has evolved technically with variable results. Farina et al.  first dea et al.  evaluatea et al.  captured2 = 0.99) with an underestimation of 0.6 %fat between replicate determinations and a technical error (LOA) of 1.51 to −1.64 %fat. Percent body fat values derived from 2D DP and DXA were correlated in groups of female and male participants (R2 = 0.88). Linearity between measured and estimated fatness was not tested but a deviation of the intercept (2.92) from the line of identity (intercept same as 0) in the plot of the female data was reported. The mean absolute error between predicted and measured %fat was 2.16 ± 1.5% for the group and was greater for females than males (2.34 ± 1.14 vs. 1.88 ± 1.32%). The 2D image analysis program slightly underpredicted %fat. Bland–Altman plots revealed no proportional bias (−0.17) among males with LOA of 4.32 to −4.56% fat but significant proportional bias  and wider limits of agreement 4.9 to −6.1% in the female group. For the combined sample of females and males, bias (−0.42) approached significance (p = 0.062) with LOA of 4.7 to −5.55 % fat.Majmudar et al.  evaluateThe burgeoning interest in the use of smartphone camera-enabled 2D DP reveals some important observations. Use of artificial intelligence, and specifically machine learning, for image analysis yields inconsistent validation results. Regardless of approach, 2D DP methods have relatively good reproducibility and similarities in group comparisons of estimated and predicted body fat variables. Although the investigators reported no significance between mean predicted and DXA-determined %fat values, proportional bias  emerged and limits general use of these models ,26. In cUse of proprietary prediction equations that fail to designate the physical characteristics and body shape variables used as independent variables confound the interpretation of findings of 2D DP measurement precision (reproducibility), trends in bias, and wide LOA ,25,26. AVariation in body position for 2D DP photography is another influence moderating the reliable characterization of body shape. Adipose tissue distribution is gender-specific and generally indicates regional adipose accumulation in obesity . Thus, dp = 0.83) than the more variable (R2 = 0.78 to 0.95) and less accurate (7 cm) 3D imaging systems for measurement of waist circumference [Our findings provide the first evidence that 2D DP is a valid method to estimate abdominal FM in adults. We found greater reliability (concordance coefficient = 0.992 to 0.995) and accuracy (0.01 to 0.04 kg; mference ,31. AlthThe present study has some limitations. The composition of the sample is limited to Caucasian adults. To expand its applicability, follow-up studies should include a more ethnically heterogenous sample. It is also important to determine the effect of BMI, a traditional indicator of adiposity, on the validity of 2D DP machine learning FM and abdominal FM estimates. To date, all studies of 2D DP have been observational. Thus, it imperative to ascertain the validity and precision of the 2D DP method to estimate changes in whole body and abdominal composition in response to weight loss, physical activity, and metabolic disease. Growing use of artificial intelligence methods, such as machine learning, for algorithm development using digital imaging will benefit from inclusion of large data sets. Therefore, future studies should focus on large, diverse samples with broad representation based on race, physical characteristics, and interventions that alter body shape and composition.In conclusion, the findings of the present study advance the use of single-image 2D digital imaging to estimate whole-body FM with the use of a novel machine learning APP that enables the very high reproducibility with negligible error in acquiring a single image for analysis. This APP coupled with an innovative machine learning model to estimate whole-body FM that yields values not different than reference DXA values. Importantly, the errors between individual 2D DP-estimated and DXA reference FM values are not negatively affected by the amount of FM. A second key result is the proof of concept that this quality control APP for image acquisition, together with a separate machine learning-derived model, accurately predicts abdominal FM, which has not previously been reported. These findings provide further incentive to adopt single scan lateral 2D DP with machine learning for practical assessment of FM in non-laboratory environments. They fulfill the need for a practical and feasible method to combine whole-body and regional body composition assessment for reliable cost-effective screening of individuals for risk of cardiometabolic disease ,14,15,17


Patch testing with the fragrance allergy markers in the European baseline series (EBS) does not identify all patients with fragrance allergy. Hydroperoxides of linalool and limonene have been shown to be useful allergens in detecting fragrance sensitization.To evaluate the added value of testing with 30 fragrance allergens in addition to the EBS.All patients with suspected fragrance allergy who underwent patch testing at the Amsterdam University Medical Centers between November 2019 and January 2021 to the EBS and fragrance series were included.Of 323 patients tested, 162 (50.2%) were found to be fragrance sensitized. The most sensitizing single allergens were the hydroperoxides of linalool (1.0 and 0.5% pet.) and limonene (0.3 and 0.2% pet.). Testing with the hydroperoxides of linalool and limonene identified 62 fragrance‐sensitized patients (38.3%) who could not be detected by the common fragrance markers. Of all fragrance‐sensitized patients, 21 (13.0%) would have been missed when not testing with the fragrance series.Patch testing with the fragrance series in addition to the EBS is valuable. To reduce the risk of false‐negative reactions, it is advisable to test the hydroperoxides of linalool and limonene. HighlightsOf the 323 patients with suspected fragrance allergy, 162 (50.2%) were found to be fragrance sensitized.Testing with the hydroperoxides of linalool and limonene identified 62 fragrance‐sensitized patients (38.3%) who could not be detected by the European baseline series (EBS) fragrance markers. When not tested with the fragrance series, 21 (13.0%) of the sensitized patients would have been missed.Routinely performing patch testing with the fragrance series in addition to linalool and limonene hydroperoxide as part of the EBS is recommended. In addition, oil of turpentine, a substance that is used as a raw material in the perfume industry, has been routinely tested due to increased sensitization rates.22.1In this retrospective cohort study, all patients with suspected fragrance allergy who had undergone patch testing with the EBS, the labeled fragrance substances, the hydroperoxides of linalool and limonene, and oil of turpentine , FMI and II. Sorbitan sesquioleate (SSO), used as an emulsifier in some allergen preparations,Myroxylon Pereirae, Evernia furfuracea, Evernia prunastri, hydroxycitronellal, and isoeugenol , oil of turpentine, and the hydroperoxides of linalool and limonene in each two dilutions . The EBS contained ol Table . The 26 2.3Prospectively collected data were extracted from the European Surveillance System on Contact Allergies (ESSCA) database of the AUMC and from electronic health records. The obtained data included demographics , atopic history, symptoms , and patch‐test results .2.4Statistical analyses were performed with SPSS, version 26.0.0.1 .2 tests or Mann‐Whitney test, as appropriate. The degree of association between categorical variables was measured by Spearman rank correlation. The correlation coefficient sizes (positive or negative) were interpreted as very high (0.9‐1.00), high (0.7‐0.9), moderate (0.5‐0.7), low (0.3‐0.5) and negligible (0.0‐0.3).p‐values of <0.05 were considered as statistically significant.Patient characteristics were presented as numbers and percentages for categorical variables and as medians with interquartile ranges (IQRs) for continuous variables. Demographic variables between groups were analyzed using χ33.1p = 0.02)  had not yet reached the age of 18 on the first day of testing and were therefore excluded. In total, 323 patients could be included in this study. The majority of these patients was female (75.9%) with a median age of 41 years (interquartile range [IQR]: 30‐54). Fragrance‐sensitized patients were significantly more likely than nonsensitized patients to have face dermatitis (3.2Evernia furfuracea(4.6%), and Evernia prunastri (4.0%). Positive patch tests to butylphenyl methylpropional and amylcinnamyl alcohol (both 0.6%) were least common. Doubtful reactions were observed for all allergens but most frequently for linalool and limonene hydroperoxide  positive patch tests to FMI and 1 of the 13 (7.7%) and 1 of the 15 (6.7%) positive patch tests to Evernia prunastri and Evernia furfuracea, respectively. The fragrance allergens Myroxylon pereirae, hydroxycitronellal, and isoeugenol did not yield concomitant positive patch‐test reactions to SSO.A total of 502 positive reactions were seen in 162 patients (50.2%) (emulsifier SSO not included). Among the individual allergens, sensitization was most frequent for linalool hydroperoxide 1.0% and 0.5% pet.  and limonene hydroperoxide 0.3% and 0.2% pet.  (Table 3.3Myroxylon pereirae (56.5%), and the hydroperoxides of linalool 1% pet. (55.1%) and 0.5% pet. (58.3%) and limonene 0.3% pet. (55.6%) and 0.2% pet. (50.0%) were most frequently considered as clinically relevant.The clinical relevance could not be assessed for 41.8% of all positive patch‐test reactions. Of the assessed reactions, 58.9% were considered clinically relevant. Sensitization to HICC (80.0%), FMII (69.5%), FMI (62.5%), 3.4Of all 502 positive patch‐test reactions, 330 (65.7%) were reactions to allergens in the EBS. In total, 172 reactions (34.3%) were identified by testing the fragrance series. Linalool hydroperoxide (1% and 0.5% pet.) and limonene hydroperoxide (0.3% and 0.2% pet.), accounted for 212 positive patch tests in 101 patients (31.3%). Of the 162 fragrance‐sensitized patients, 94 (58.0%) had their allergies fully defined by the EBS alone and 21 (13.0%) fully by the fragrance series alone  were also sensitized to at least one of the single constituents of the mix. Concerning FMII, this was the case for 10 of 26 patients 38.5%) . All three patients positive to unoxidized linalool also patch tested positive to oxidized linalool. Only two of the five patients who tested positive to unoxidized limonene had concomitant positive patch‐test reactions to its oxidized form. Of the patients sensitized to limonene hydroperoxide (0.3% pet.), 93.9% had a concomitant reaction to the less concentrated form 0.2% pet.). Concomitant reactions to the fragrance series in patients sensitized to oxidized linalool or oxidized limonene varied between 32.1% and 39.4%  of the four sensitized patients. Allergens that yielded one concomitant reaction were FMII, HICC, citral, hydroxycitronellal, eugenol, Evernia prunastri, isoeugenol, cinnamaldehyde, and benzyl cinnamate.Oil of turpentine yielded a sensitization rate of 1.2%, as four patients reacted positive. Seventy‐five percent of the patients with positive patch‐test reactions to oil of turpentine had concomitant positive patch‐test reactions to FMI, 4In this retrospective cohort study, the added value of testing with the hydroperoxides of linalool and limonene, the EU‐labeled fragrance allergens, and oil of turpentine, in addition to the EBS, was evaluated. If only the EBS was tested, 34.0% of the sensitized patients would not have had their allergies fully defined and 13.0% would have remained undetected as fragrance allergic. Without patch testing with the hydroperoxides of linalool and limonene, 38.3% of all fragrance‐sensitized patients would be missed. Therefore, it is valuable to perform patch testing with the fragrance series in addition to the EBS. Patch testing with the hydroperoxides of linalool and limonene in the EBS will reduce the risk of false‐negative reactions, vs testing with nonoxidized linalool and limonene.4.1Myroxylon pereirae and methyl‐2‐octynate were not included as fragrance allergens in the Danish study.Fragrance sensitization was present in about half of our patch‐tested patients (50.2%) and was significantly associated with facial dermatitis. Lower rates of fragrance allergy (7.6%‐ 26.9%) were reported in previous studies.4.2As expected, the hydroperoxides of linalool 1.0% and 0.3% pet. and limonene 0.3% and 0.2% pet. were among the most sensitizing .4.3Rates of concomitant sensitivity among patients positive to the fragrance series were 61.0% to FMI and 28.5% to FMII. The higher concomitant sensitivity to FMI than to FMII is in line with previous reports.4.4Evernia furfuracea (4.6%), and Evernia prunastri (4.0%) were the most sensitizing. This is in line with previous reports, especially for the last two allergens.Evernia prunastri is attributable mostly to its allergic compounds chloroatranol and atranol.Evernia furfuracea can be divided into two subgroups: those with sensitization to common constituents as also present in Evernia prunastri, and those sensitized to oxidized resin acids as present in the contaminating tree bark which is used in the extraction process. This latter subgroup was identified by positive reactions to colophonium.Evernia furfuracea had positive co‐reactions to colophonium. Two of these double‐sensitized patients (40%) reacted negative to Evernia prunastri. The high co‐sensitization rate to colophonium among patients sensizited to Evernia furfuracea in combination with the fact that not all patients were sensitized to Evernia prunastri supports the heterogeneity in this sensitized group.Among the EU‐labeled allergens, citral (6.2%), Myroxylon pereirae, and a recommended addition to the EBS: linalool hydroperoxide 0.5% pet. Only one of the four sensitized cases in the current study remained undetected by the fragrance markers; therefore, the added value of patch testing this substance consecutively is questionable.Citral is a mixture of the two aldehydes geranial and neral. These compounds have also been found in the oxidation process of geraniol. Just like linalool and limonene, geraniol has the potential to form allergenic compounds by autooxidation on air exposure.4.5Selection bias might have been introduced by including patients suspected of having fragrance allergies. Referral bias and missing clinical relevance data are limitations of this study. In addition, the sources of exposure were not investigated.5In conclusion, testing with the hydroperoxides of linalool and limonene in each two dilutions has been useful to identify fragrance‐sensitized patients who could not be detected by the common markers. Testing with the fragrance series of 26 detects even more fragrance‐allergic cases and can help in advising what allergens to avoid. We recommend routinely performing patch testing with the fragrance series in addition to linalool and limonene hydroperoxide as part of the EBS in all patients with suspected fragrance allergy. Future studies are needed to evaluate the possible added value of testing the oxidized form of geraniol.None declaredRosalie C. Krijl: Conceptualization (lead); formal analysis (lead); investigation (lead); methodology (lead); visualization (lead); writing – original draft (lead); writing – review & editing (lead). Norbertus A. Ipenburg: Conceptualization (lead); data curation ; investigation (supporting); methodology (supporting); project administration (lead); resources (lead); writing – review and editing (lead). Sylvie M. Franken: Conceptualization (supporting); data curation ; writing – review and editing (supporting). Thomas Rustemeyer: Conceptualization (supporting); Data curation ; Methodology (supporting); Supervision (Lead); Visualization (supporting); Writing – review & editing (supporting).Appendix S1.The fragrance allergens per test series included for this study.Appendix S2. Correlation analysis between the oxidized forms of linalool and limonene and the fragrance allergens from the European baseline series and fragrance series. Spearman rank correlation (R) along with its p‐values are tabulated.Appendix S3. Demographic characteristics according to the MOAHLFA index for all patients testedClick here for additional data file.


Ventricular septal defects (VSDs) are one of the leading causes of death due to cardiac anomalies during the first months of life. The prevalence of VSD in neonates is reported up to 4%. Despite the remarkable progress in medication, treatment and surgical procedure for VSDs, the genetic etiology of VSDs is still in infancy because of the complex genetic and environmental interactions.Three hundred fifty subjects  were recruited from different pediatric cardiac units. Pediatric clinical and demographic data were collected. A total of six variants, rs1017 (ISL1), rs7240256 (NFATc1), rs36208048 (VEGF), variant of HEY2, rs11067075 (TBX5) and rs1801133 (MTHFR) genes were genotyped by tetra-ARMS PCR and PCR–RFLP methods.The results showed that in cases, the rs1017 (g.16138A > T) variant in the ISL1 gene has an allele frequency of 0.42 and 0.58 respectively for the T and A alleles, and 0.75 and 0.25 respectively in the controls. The frequencies of the AA, TA and TT genotypes were, 52%, 11% and 37% in cases versus 21%, 8% and 71% respectively in the controls. For the NFATc1 variant rs7240256, minor allele frequency (MAF) was 0.43 in cases while 0.23 in controls. For the variant in the VEGF gene, genotype frequencies were 0% (A), 32% (CA) and 68% (CC) in cases and 0.0%, 33% and 67% respectively in controls. The allele frequency of C and A were 0.84 and 0.16 in cases and 0.83 and 0.17 respectively in controls. The TBX5 polymorphism rs11067075 (g.51682G > T) had an allelic frequency of 0.44 and 0.56 respectively for T and G alleles in cases, versus 0.26 and 0.74 in the controls. We did not detect the presence of the HEY2 gene variant (g.126117350A > C) in our pediatric cohort. For the rs1801133 (g.14783C > T) variant in the MTHFR gene, the genotype frequencies were 25% (CC), 62% (CT) and 13% (TT) in cases, versus 88%, 10% and 2% in controls. The ISL1, NFATc1, TBX5 and MTHFR variants were found to be in association with VSD in the Pakistani pediatric cohort whilst the VEGF and HEY2 variants were completely absent in our cohort.We propose that a wider programme of genetic screening of the Pakistani population for genetic markers in heart development genes would be helpful in reducing the risk of VSDs. GATA4), VSD2 (CITED2) and VSD3 (NKX2.5) [ISL1 gene is one of the important pioneer factors for cardiomyocyte differentiation. ISL1 is a LIM homeodomain transcription factor expressed transiently in the second heart field [ISL1 serves as marker for progenitor cells. The human ISL1 gene is located on chromosome 5q11.1 [ISL1 gene knockout experiment in a mouse model has demonstrated the importance of this gene as knockout mice embryos died due to defects in heart development [ISL1 has been reported in association with congenital heart disease in humans [NFATc1 via the activation of their heterogenic promoters [NFATc1 gene is located on chromosome 18q23. Studies have reported genetic mutations in NFATc1 as the cause of atrio-ventricular septal defects (AVSD) [VEGF) plays a key role in morphogenesis of the vascular system and differentiation of endothelial cells [VEGF gene is located on chromosome 6p21.1. VEGF knockout experiments in mice have resulted in sudden death of 55% of animals. Even a single copy of the VEGF gene is not sufficient for the survival of mutant mice [VEGF, rs36208048 (NG_008732.1:g.3877C > A) has been reported in association with VSD [TBX5 is primarily known for cardiac forelimb development. It also acts as transcriptional activator for the genes specifically associated with cardiomyocyte maturation. The human TBX5 gene is located on chromosome 12q24.21 [TBX5 and VSDs [The most obvious cardiac abnormality of juveniles is ventricular septal defects (VSDs) as they encompass about 40% percent of all hereditary cardiac abnormalities in the form of an isolated defect. Ventricular septal defects are one of the leading causes of death in childhood during the first month of life . The preSD3 NKX2. [ISL1 geelopment . A SNP, n humans . NFATc1 n humans . Gene exromoters . The hums (AVSD) . A polymant mice . In humawith VSD . T-Box twith VSD . TBX5 is12q24.21 . Earlierand VSDs , 17.Hey2 gene) belongs to a small family of HEY members consisting of basic helix loop helix (bHLH) transcription factors [HEY2 gene is located on chromosome 6q22.31. Genetic variants in the HEY2 gene cause heart defects [MTHFR, a methylene tetrahydrofolate reductase, is an enzyme which catalyses synthesis of the initial circulatory form of folate, which in turn acts as a donor of methyl group for re-methylation of homocysteine to methionine [MTHFR gene is located on chromosome 1p36.22. A common variant in MTHFR, rs1801133 (NG_013351.1:g.14783C > T), has been previously studied [ISL1: rs1017 (NG_023040.1:g.16138A > T), NFATc1: rs7240256 (NG_029226.1:g.23449 T > C), VEGF: rs36208048 (NG_008732.1:g.3877C > A), TBX5: rs11067075 (NG_007373.1:g.51682G > T), HEY2: (NC_000006.10:g.126117350A > C) and MTHFR: rs1801133 (NG_013351.1:g.14783C > T), with VSD. The identification of different genetic polymorphisms in association with VSDs will aid surveillance and screening of VSD patients, facilitate genetic counselling and may help reduce the prevalence of this condition in the local region.Hairy enhancer of split related with YRPW motif protein 2 . Written informed consent was taken from the parents or guardians of patients. Two hundred samples  from isolated VSD patients were recruited from various pediatric cardiac wards of Lahore, Pakistan. One hundred and fifty healthy controls with no cardiac defects were included in this study. Sampling was done from 2018 to 2020.The patients diagnosed with isolated ventricular septal defects were selected via ECG. The image of the heart was captured by two dimensional and Doppler echocardiography to identify the magnitude of the shunt, the size and location of the defect (the whole structure of heart). During cardiac catheterization, the blood flow rate, the Qp/Qs ratio were also measured to determine the shunt size. Echocardiograms were performed by expert pediatric cardiologists. Cases and controls with syndromic VSD, other cardiac issues and infectious diseases (seropositive for HBV/HCV/HIV) were excluded.Data from pediatric patients were collected on the basis of different parameters: hematological parameters like WBCs, RBCs, Hb level, platelets count, serum creatinine (SC), calcium, sodium, blood urea nitrogen (BUN), potassium, serum glutamic pyruvic transaminase, bilirubin, serum glutamic oxaloacetic transaminase, serum albumin, alkaline phosphate, and gamma GT etc., and demographic data like age, consanguineous marriage, family history, maternal Hb level during pregnancy. Use of medicine during pregnancy etc. was also recorded.uL. The tetra primer ARMS PCR technique was used for the amplification of the MTHFR, NFATc1 and TBX5 genes  and DNA concentration was adjusted to 10 ng/2) whereas allelic frequencies were calculated by direct counting. Genotypic and allelic frequencies were reported as percentages. Mean and standard deviation values were calculated for quantitative parameters. The study population was tested for Hardy–Weinberg equilibrium. As we analyzed 6 SNPs, the Bonferroni adjusted p-value (0.0125) was used as a threshold of significance for all analyses.For the statistical analysis, the software SPSS version 22 was used. Genotypic frequencies of cases and controls were analysed using the chi-squared test , 11% (TA) and 37% (TT) in cases in comparison to 21%, 8% and 71% respectively in controls . The genotype frequencies deviated from Hardy–Weinberg equilibrium for the cohort . The genotypic distribution in dominant and recessive models is demonstrated in Table p-value: < 0.0001, Recessive: OR: 0.24 CI: 0.13–0.43, p-value: < 0.0001, allelic OR: 0.242, CI: 0.157–0.37, p-value: < 0.0001) , 78% (TC) and 18% (TT) in cases compared to 1.0%, 44% and 55% in controls . In the dominant model, the OR was 0.18 with CI 0.09–0.34 and p-value < 0.0001 and in the recessive model OR was 0.24 with CI: 0.03–2.23  . Genotyping of rs36208048 (g.3877C > A), variant in the VEGF gene showed that the percentage of the AA, CA and CC genotypes were 0%, 32% and 68% respectively in cases versus 0%, 33% and 67% in controls . For the cohort, the genotype frequencies showed deviation from Hardy–Weinberg equilibrium . For the dominant model the OR was 1.06 with CI: 0.59–1.92 . While recessive model analysis could not be performed due to absence of homozygous genotype in cases as well as in controls (Table For the rs7240256 g.23449 T > C) 449 T > CTBX5, the frequencies of the GG, GT and TT genotypes were 21%, 70% and 9%, respectively in cases, versus 56%, 36% and 8% in controls . In the dominant model, the OR was 0.21 with CI 0.11–0.38 and p-value < 0.0001 versus in the recessive model, the OR was 0.89 with CI 0.33–2.40 and p-value 0.82 . For the variant in HEY2: (g.126117350A > C), we did not detect the homozygous or the heterozygous genotypes. Therefore, dominant and recessive model analysis could not be performed in the cases or in controls. Dominant homozygous frequency was 1.0, both in cases and controls. The genotyping of rs1801133 (g.14783C > T) variant in MTHFR showed that the frequencies of the CC, CT and TT genotypes were 25%, 62% and 13%, respectively in cases, while 88%, 10% and 2% in controls . In the dominant model, the OR was 0.04 with CI 0.02–0.10  while in the recessive model, the OR was 0.14 with CI 0.33–0.63 and p-value 0.002 .For the polymorphism, rs11067075 g.51682G > T) in G > T in GATA4, NKX2.5, TBX5, VEGF, MTRR, MTHFR, ISL1, NFATC1 and CITED2 play crucial roles in the etiology of VSD [ISL1, NFATc1, VEGF, HEY2, TBX5 and MTHFR) selected in this study are important structurally as well as functionally in cardiovascular system (Fig. The healthcare burden of congenital heart disease is gradually increasing worldwide and more specifically in the low- and middle- income countries like Pakistan, where the cost of treatment is unaffordable for most families. Generally, the Pakistani population shows remarkable variations in the investigation of genetic diseases due to high rates of consanguineous marriages, a fact that makes this population attractive to geneticists. Advances in the field of genetics have led to the discovery of novel genetic markers for complex as well as for monogenic diseases . Ventricy of VSD . Due to ISL1 LIM-homeodomain transcription factor substantially contributes to embryonic heart development. It is one of the genes responsible for ventricle development [The elopment . Based oelopment . A studyelopment . In contelopment . Surpriselopment . Our reselopment . Higher elopment . From ouelopment .TBX5 transcription factors maintained their expression level throughout heart development and their persistent expression has also been observed in ventricular maturation , 32. OurISL1, NFATc1, VEGF, HEY2, TBX5 and MTHFR genes with VSDs in a Pakistani cohort.The Pakistani population is unique, in regard of its social, cultural, religious practices; it also has been reported to have a high percentage of consanguinity. This makes genetic research and in particular the study of complex genetic disorders including VSDs extremely challenging, but potentially rewarding. Although samples can be recruited from the entire country, their total number is limited due to lack of resources. This is the first attempt to determine the possible association of variants in the


Evidence of tubular atrophy and interstitial fibrosis is prognostically unfavorable and associated with a premature graft loss after kidney transplantation. Recently, Dickkopf 3 (DKK3), a profibrotic glycoprotein released by stressed tubular epithelial cells, has been identified to cause IF/TA by regulating the Wnt/β-catenin signaling and seems to engage a T-cell response. The aim of our study was to determine if a correlation between DKK3 and graft function exists and if DKK3 could be a new indicator to identify patients at risk for a deterioration in graft function. Patients, transplanted between 2016 and 2018, were analyzed with regard to DKK3 in the urine and graft function . Multivariable analyzes were used including known factors influencing graft function  to stress robustness of DKK3. The 3 and 12 month DKK3 values were significant predictors for subsequent graft function up to 36 months. An increase of DKK3 from month 3 to 12 of ≥ 25% showed a higher risk of an impaired graft function, with, e.g., a reduction in eGFR of about 9–10 ml/min in contrast to patients without intensified DKK3 increase. Induction therapy has an influence on DKK3 as patients induced with a T-cell depleting therapy showed a trend toward lower DKK3 values. In summary, our study is the first investigation of DKK3 in kidney transplant recipients and was able to show that DKK3 could forecast graft function. It is recommended to investigate the potential of DKK3 as a predictor of kidney function after transplantation in further studies. Kidney transplantation remains the preferred treatment for patients with end stage kidney disease due to a better patient survival compared to dialysis. Despite good short-term results, ensuring a long-lasting graft function is an unsolved problem. To date, with serum creatinine, eGFR and albuminuria, only a few parameters are available in everyday clinical practice to monitor graft function. Even in the KDIGO guidelines, these parameters are named as the main monitoring tool . HoweverPark et al. showed that an eGFR decline of >–10% in a period of 3–12 months was associated with a greater risk of graft failure  . These hThe “iBox,” a prediction score by the group of Loupy et al., aims to ensure a better graft monitoring and thus enable a patient-tailored diagnostic and therapy after transplantation . TrailinDickkopf 3 (DKK3) has been identified as a biomarker of kidney function in animal and clinical studies. These studies have been based on patients with acute kidney injury (AKI) or chronic kidney disease (CKD). In the context of AKI, DKK3 is currently seen as a prediction score for the development of a kidney failure .DKK3, a profibrotic glycoprotein, belonging to the Dickkopf family consists of five proteins  that influence the Wnt signaling pathway through inhibition or activation. The Wnt signal pathway is an important signal transduction pathway in embryogenesis , 10. It Frederico et al. found that Dickkopf plays a role in embryonic development and was found in mesenchymal progenitor cells and mesenchymal cells. It is normally not detectable in adult cells . After kStudies on patients with CKD have shown that high Dickkopf values are associated with the increased incidence of tubulointerstitial fibrosis. Frederico et al. were able to show that DKK3 deficient mice showed less pronounced tubular atrophy and an improved kidney. This effect could also be demonstrated by an antibody-mediated blockade of DKK3 . AnotherThe role of Dickkopf 3 in the context of kidney transplantation is completely unclear. The aim of our study was to analyze DKK3 in the urine of transplanted patients, which represents the first investigation realized in such a cohort. For this purpose, a highly standardized cohort of kidney transplant recipients was investigated. In addition to kidney function, represented by creatinine, eGFR and albuminuria, both donor and recipient specific influencing factors  were analyzed. The goal of our study was to determine if a correlation between the DKK3 values and graft function over the observation period of 3 years exists and if DKK3 could be further developed as a non-invasive marker to identify patients at high risk for a deterioration in transplant function.n = 122). All recipient-related data and transplantation-associated parameter were collected and archived as part of the “Regensburger Transplantationsnachsorge.” This retrospective study was approved by the Ethical Committee of the University of Regensburg.All patients being transplanted at our center between January 1, 2016 and December 31, 2018 were included  and urinary albumin/creatinine ratio up to 36 months after transplantation was analyzed. Each recipient was grouped according to its underlying immunological risk profile  before transplantation and thereafter treated by a pre-defined immunological algorithm . InductiUrinary midstream samples were collected from patients at the mentioned time points. The urine samples were stored at −80°C. DKK3 was measured with a commercially available ELISA according to the manufacturers' recommendations . Urine samples were centrifuged at 370 g for 10 min. 100 μL of supernatant was mixed with 900 μL of sample buffer and 100 μL of the dilution was transferred to a microtiter plate coated with capture antibody and incubate for 30 min (23 ± 3°C). After repetitive washing (3x), the detection antibody was loaded with streptavidin-horseradish peroxidase (HRP) conjugate and rinsed again (3x). Substrate solution (100 μL of TMB/tetramethylbenzidine) was added and incubated for 30 min at room temperature. Finally, 100 μL of stop solution per well was added and the plate was immediately measured at 450 nm. For each microtiter plate, 6 standards were carried in duplicate at DKK3 concentrations of 0, 30, 85, 245, 700, and 2,000 pg/mL. Concentration data in urine are not very meaningful because the results depend on the dilution state of the urine. Accordingly, urinary DKK3 levels were normalized to urinary creatinine concentrations to account for dilution of the urine . To exclDescriptive analyses were done using absolute and percentual frequency , mean ± standard deviation, and median with corresponding interquartile range (IQR).The course of DKK3, creatinine, eGFR, and albuminuria values from 14 days up to 3 years after transplantation were presented.U-tests were used to compare DKK3 crea ratio 3 months and 12 months postTx between patients treated with basiliximab or rATG. The time point 14d was excluded due to the presumably influence of reperfusion ischemia damage.Mann- Whitney- The associations between DKK3 crea ratio and graft function were assessed by three separate mixed linear models (MLM) including the measurement time points 12, 24, 30, and 36 months. It was examined whether the 3 or 12 month DKK3 value can predict graft function in the following course using six separate MLMs. The influence of changes in DKK3 values from month 3 to month 12 after transplantation on subsequent graft function 24, 30, and 36 month after transplantation was assessed by three separate MLMs. Changes in DKK3 were dichotomized in worse (≥ 25% increase) and good (<25% increase). With these analyses, we investigated whether DKK3 represents an independent influencing factor on kidney function and if a change in DKK3 kinetics is relevant. 25% was chosen as cut-off, in accordance to the classification of an AKI, where a 25% deterioration in kidney function is classified as stage 1 (RIFLE criteria) . In the The MLMs included factors that that are well-known to affect graft function, namely highest PRA level , cold anStatistical analyses were conducted with SPSS Statistics 26 . The level of significance was set at p two-sided ≤ 0.050. No adjustments for multiple testing were done.A total of 122 patients were transplanted with 85 being men (70%) and 37 (30%) being women. Induction therapy with basiliximab was carried out in 82 patients (67%) and 39 patients received rATG (32%). One patient received no induction therapy (1%). The mean donor age was 56 years . The cold ischemia time averaged 480 min , the warm ischemia time was 42 min . Donor-specific antibodies were detected in 11 patients prior to transplantation (9%). Out of the 122 transplants performed, 41 were from a living donation (33.6%) from which 17 were from blood relatives (41.5%) and 81 were from a cadaveric donation (66.4%). Forty-nine patients received an organ from a donor with extended donor criteria (ECD) (40.2%). Eight patients died during the follow-up. Further information are shown in We analyzed the course of DKK3 over the observation period of all transplanted patients. The highest DKK3 value with a median of 2,509 pg/mg crea  were measured after 14 days. In the further course the following median values were measured: 3 months: 300.5 pg/mg crea ; 12 months: 771.5 pg/mg crea ; 18 months 742 pg/mg crea ; 24 months: 491 pg/mg crea ; 30 months: 430 pg/mg crea ; and 36 months: 661 pg/mg crea  .Stable creatinine values over the entire 36 months were seen: 14d: 2.08 mg/dl (1.54–2.73); 3 months: 1.62 mg/dl; (1.34–1.92) 12 months: 1.51 mg/dl (1.18–1.96); 18 months: 1.39 mg/dl (1.17–1.82); 24 months: 1.48 mg/dl (1.16–2.01); 30 months: 1.35 mg/dl (1.05–1.84); 36 months: 1.47 mg/dl (1.11–2.03) . In accoThe following albuminuria values were measured: 14d: 78.50 mg/g crea (46.9–201.75); 3 months: 29.35 mg/g crea (16.95–70.40); 12 months: 26.75 mg/g crea (9.42–60.93); 18 months: 29.30 mg/g crea (9.63–69.85); 24 months: 38.50 mg/g crea (13–85.08); 30 months: 29.90 mg/g crea (11.2–90.60); 36 months: 23.80 mg/g crea (10.3–89.50). Two patients showed clear outliers at the time points 24 months  and 30 months . In both patients the albuminuria was associated with a subsequent graft loss .n = 79); 12 months: median = 941 pg/mg crea ] than patients treated with rATG    .p < 0.001) and DKK3 expression level (p = 0.011) were significantly associated with impaired graft function. More precisely, if the donor age increased by 10 years, resulting creatinine increased by 0.11 mg/dl and if the DKK3 increased by 10.000, creatinine increased by 0.16 (95% CI 0.09–0.23). The analysis of the eGFR showed that donor age (p < 0.001) and last donor creatinine (p = 0.03) were the only influencing factor, whereas DKK3 did not reach the level of significance (p = 0.13). In the case of albuminuria, both donor age (p < 0.001), donor diabetes (p = 0.03) and the DKK3 value (p < 0.001) were statistically significant (Tables 1a–c of the The mixed linear models showed that higher donor age (p < 0.050) up to 36 months. Moreover, higher DKK3 values 3 and 12 months postTx predicted lower subsequent eGFR values (p < 0.050) in the same observation period. Higher DKK3 values 3 months after transplantation predicted higher albuminuria values 6 months (p = 0.013) and 12 months postTx (p = 0.050), but not on a later time point (p > 0.050). Higher DKK3 values 12 months after transplantation predicted higher subsequent albuminuria values up to month 36 (p < 0.050). Donor age was the only consistently significant parameter associated with graft function (p < 0.050), whereas the other analyzed parameters showed no consistent influence. More precisely, an increase in donor age by 10 years lead to a creatinine increase of 0.13 mg/dl, while an increase in DKK3 by 10.000 lead to a creatinine increase of 0.58 mg/dl , a lower eGFR (p = 0.018) and higher albuminuria values (p = 0.005) for subsequent time points. These associations could be confirmed for graft function 30, and 36 months postTx (p < 0.050), except for albuminuria values 36 months after transplantation (p = 0.092)  . RoughlyIn our study, we examined the influence of Dickkopf 3 on graft function in kidney transplant recipients. We were able to show that DKK3 correlates with resulting graft function, represented by creatinine, eGFR and albuminuria, over an observation period of 36 months. DKK3 can even predict kidney function as illustrated by the association of 3 and 12 months DKK3 values and subsequent allograft function. Furthermore, changes in DKK3 values from month 3 to 12 (≥25%) were associated with a significantly deteriorated graft function, being illustrated by tremendous differences in creatinine, eGFR, and albuminuria values. Our study is the first investigation of DKK3 referring to transplantation medicine.Regarding the function of DKK3, studies have shown that DKK3 is secreted only by stressed tubular epithelial cells in the adult kidney. Using two animal models, an adenine-induced nephropathy and a model of an unilateral ureter obstruction, Gröne et al. showed by usage of a DKK3 knockout that DKK3 deficiency leads to a marked reduction in tubular damage and renal fibrosis. DKK3 deficiency triggered an antifibrotic T cell response and reduced activity of the WNT–β-catenin signaling pathway. These results could also be reproduced by an antibody-mediated blockade of DKK3. DKK3 therefore appears to be an important mediator of renal fibrosis and thus of deterioration in renal function .Schunk et al. were able to show that patients after cardiac surgery and increased DKK3 scores (>471 pg/ml) had an increased risk for developing AKI . A compaZewinger et al. were able to show that high levels of DKK3 are associated with impaired function in patients with CKD. DKK3 could be seen as a predictor for an eGFR loss independent of the underlying disease. This study showed that high DKK3 values can function as a prognostic parameter regardless of the accompanying albuminuria . SimilarWe were able to see a trend toward lower DKK3 values after T-cell depleting induction therapy in comparison to an immunomodulatory therapy with basiliximab. Regarding the impact of immunosuppressives on the development of DKK3, no further data are available. But in literature, the influence of DKK3 on T- lymphocytes is discussed. As already mentioned, DKK3 seems to trigger a profibrotic T cell response. Federico et al. were also able to show that after an antibody-mediated blockade of DKK3, an increased presence of protective T cells (IFNγ-producing Th1 and Tregs) can be demonstrated . Taking In our cohort, we were able to recognize a total of 18 rejections over the entire observation period, both T cell-mediated and antibody-mediated rejections. Most of them occurred within the first 14 days. The analysis of the DKK3 values between patients with a rejection compared to patients without a rejection showed no statistically significant difference. However, it should be noted here that there is a relevant difference in the number of cases in the two groups as a possible confounding factor.Our study is the first analyzing Dickkopf 3 after kidney transplantation. Nevertheless, it is a monocentric study with a limited case number. There are currently no special biomarkers postTx available to estimate the individual risk for a deterioration in graft function. DKK3 can be easily integrated into everyday clinical practice thanks to its detection in urine. Similar to Zewinger in his study, we were also able to see a clear influence of DKK3 on graft function . The useWhereas, in the context of chronic kidney disease, Dickkopf 3 has been recognized as a marker to identify patients at risk for a progressive loss of kidney function, to date, the impact of DKK3 after transplantation has not yet been analyzed.In our study on kidney transplant recipients, DKK3 not only could precisely predict subsequent allograft function but an increase in DKK3 values within the first year after transplantation was associated with a deterioration in allograft function.With the presented data, DKK3 can be considered as a new indicator of impaired graft function after transplantation. However, further prospective and interventional studies are needed to verify our findings.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Ethical Committee of the University of Regensburg. The patients/participants provided their written informed consent to participate in this study.AS, BB, and TB: concept/design. AS, PF, and TB: data collection. AS, KM, FZ, and TB: statistics. AS, LS, and TB: data analysis/interpretation. AS, LS, BB, and TB: drafting article. AS, LS, KM, FZ, PF, BB, and TB: critical revision of article and approval of article. All authors contributed to the article and approved the submitted version.This work was funded by the Deutsche Forschungsgemeinschaft , project number 387509280, SFB 1350 Project B6 to TB and BB.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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The contamination of raw milk depends on the number and type of organisms that can cause health risks, which can be judged by the presence of microorganisms and bacterial pathogens. This study evaluated bacterial contamination, the risk factor, and drug sensitivity patterns. P value less than 0.05 was considered to be statistically significant.  A cross-sectional study was carried out on conveniently selected 95 milk producers. Data were collected using the structured pretest questionnaire and the observation control list. Subsequently, 15 to 20 ml of milk samples were taken for laboratory analysis. The milk samples have been diluted and continuously inoculated on the number of standard plates and the blue Eosin methylene germs for the total number of bacteria and coliforms counted. Biochemical and drug sensitivity tests have been done. The version 21 Statistical Package for the Social Sciences was used for analysis. Analysis of the associated factors using binary logistical regression analysis and a E. coli (30.7%), Staphylococcus aureus (16.7%), and Salmonella spp. (1.2%). Among isolated bacteria, 76.3% were extensive drug resistant, 13.2% were multidrug resistant, and 2.6% were resistant to all drugs tested in the current study.  The total bacteria (TBC) and coliform count (CC) average with the standard deviation were 7.57 ± 0.83 log10 and 6.54 ± 1.53 log10 CFU/mL, respectively. The prevalence of raw milk contaminated with TBC and TCC was 84 (88.4%) and 75 (78.9%), respectively. Lack of handwash practice before milking (AOR = 2.4 [95% CI: 0.35–16.4]) and using unclean milk containers (AOR = 7.47 [95% CI: 0.0023–28.64]) were found to be significantly associated with bacterial contamination of raw milk. The bacteria isolated were  Guaranteed appropriate hygiene exercise during time of milking and clean containers reduced milk contamination. Doctors should consider resistance to drugs during the treatment of patients with milk disease. Raw milk is a dairy product that promotes body tissue growth and maintenance by providing the necessary nutrients like proteins, energy, minerals, and vitamins . BiologiMilk and other dairy products are useful for nourishing the pastoral community in Ethiopia. In lowland parts of the country where livestock rearing is the main occupation, the majority of social groups consume raw milk . Raw milStaphylococcus aureus (SFP) is also the most widespread cause of gastroenteritis in the world [E. coli O157 : H7 is the other most important food mediator, causing human diarrhea, hemorrhagic colitis, and hemorrhagic therapy syndrome. Clear links between consuming raw milk and human illness were found in the cases of Campylobacter spp., Salmonella spp., Brucella melitensis, and Mycobacterium bovis [Milk contaminated with pathogenic bacteria is a major cause of foodborne disease, which is a serious health problem for millions of people in the world. Food-related diseases causing mortality or other complications due to contaminated milk increase every day and create a significant burden on the healthcare system . Among fhe world . In addium bovis .Food-associated diseases are responsible for 33 to 90% of the deaths of children in Africa, and represent serious problems of the continent .Overdose, misuse, and prolonged use of drugs for treatment of animals and humans lead to an alarming increase and distribution of antimicrobial resistant bacteria. This is worsening the clinical scenario and is one of the greatest medical challenges of our time. It is also the reason for low cure rates, loss of human life, and animal life, and animal milk products .Generally, raw milk and dairy product contamination control is not done on a daily basis in Ethiopia . This siThis study was conducted in the Oromia regional state, Borena zone, Gomole district, Southern Ethiopia from March 1 to April 30, 2019. The Gomole District is one of the 10 districts in the Borena zone and 525 km South of Addis Ababa, located on the Addis Ababa-Moyale highway. The Gomole district has 67,798 people in total and more than 90% of the population is in pastoral communities. This district is dry and semiaged, and the average annual daily temperature varies from 17°C to 30°C with a bimodal season. According to Animal Statistics in 2018, the region has 37,000 cows, 14,890 camels, and 108,222 goats. Raw milk and dairy products are the main export products to neighboring areas and cross the border to Kenya.A cross-sectional study design was used on the conveniently selected study participants in the Gomole district of Borena zone. Raw milk not from selected kebele of Gomole district and their owners were excluded from the study. During the study period, milk from producers in selected Kebeles was included in the study, while the milk from vendors and milk imported from outside the selected kebeles was excluded from the study.Using the double population proportion formula, the sample size was calculated by Epi Info Version 7.2.1.0  with theThe pretested structured questionnaires and observation checklists were used to collect data through face-to-face interviews with the participants. The questionnaire contains sociodemographic characteristics, such as age and sex, and other factors that can contaminate raw milk during observation to gather data on conditions around milk, containers, and the surrounding environment  file. Th−7 . One milliliter (mL) of diluted milk portion was taken and inoculated into sterile standard plate count agar media and eosin methylene blue agar (EMB) media  (6 CFU/mL (<6.3log10) and contaminated if >2 × 106 (>6.3log10) CFU/mL [10) CFU/mL was accepted as noncontaminated [Total bacteria number and coliforms were counted by culturing on standard plate count agar and eosin methylene blue agar (EMBA), respectively. 1 mL of milk was transferred to a sterile test tube which contained 9 mL of sterile peptone water. The mixture was then serially diluted up to 10oke, UK)  file. Th) CFU/mL . The tot) CFU/mL . The resaminated .Escherichia coli bacteria were isolated from coliform contaminated raw milk by culturing on eosin methylene blue agar (EMBA) plates. Then one or two typical greenish metallic sheen suspected colonies were examined with the Gram staining technique, and Gram-negative bacilli isolated were determined biochemically [Salmonella species isolation, one millileter of raw milk portion was added into 9 mL of lactose broth and incubated at 35°C overnight. Then, one milliliter of diluted milk was inoculated in to 10 mL selenite F broth for preerichment and incubated at 35°C overnight. From enrichment media, a loop full of sample was inoculated on Xylose-lysine decarboxylase (XLD) and incubated at 35°C overnight  plates and incubated at 35°C overnight. When one or two yellowish suspected colonies grew on the media, pure colonies were transferred from MSA plate into nutrient broth (NB) tubes and incubated at 35°C overnight. Then one loop full of suspension was inoculated onto nutrient agar and incubated at 35°C overnight. Then Gram staining examination, catalase, and coagulase test were performed on pure isolated colonies. The colonies formed clotting/clumping with coagulase test were considered as Staphylococcus aureus . Three to five pure colonies of bacteria were collected and added into the tube that had 4 to 5 mL physiological saline and were gently mixed in the solution to adjust homogeneous turbidity with McFarland 0.5 standard. The sterilized swab cotton in the prepared suspension was dipped and sprayed on the whole surface of Mueller–Hinton Agar (UK) in accordance with the directives of the Standard Clinical and Laboratory Research Institute . Then, fE. coli, S. aureus, and S. typhimurium were used for culture quality check.The quality of the data obtained is guaranteed by following the standard procedure at each stage of the task. The questionnaire on this study was adopted in previous studies and was developed in the region. The questionnaire was pretested in advance with the completeness, and the adequacy of the regional context was tested on 5% of the participants at the District of Fichwa. Some questions have been set according to the results before the test. Daily data collectors, supervisors, and main researchers confirmed the questionnaire on site after data collection. The calibrated equipment was used to measure the reagents and other materials before using them in the process. The quality of the reagents, antibiotic discs, and disinfection solutions was guaranteed according to the manufacturer's management, and the expiration date has been confirmed. Before the distribution, the antibacterial disc was held at room temperature for 1 hour. The culture medium was applied and sterilized according to the manufacturer's directives, and then the sterile media were inspected by incubating 3 to 5% of the lot at 35°C overnight. Collection of American Culture of type (ATCC) reference species such as p values less than 0.25 (p < 0.25) were included in multivariate analysis. Multivariate logistic regression was performed to control for potential confounders. The model fitness was checked using the Hosmer–Lemeshow goodness-of-fit test. Finally, the strength of associations between outcome and determinant variables was expressed using adjusted odds ratios (AORs) with 95% confidence intervals, and the significance of associations was declared at a p value of less than 0.05.The data were checked for completeness and consistency, and double data entry was made using Epi-data version 3.5.1 software. Then, the data were exported to SPSS version 21 for further analysis. The total bacterial and coliform count results were interpreted as direct and converted into Log10 CFU/mL. Descriptive statistics such as percentage and frequency were computed, and the mean with standard deviation or median with interquartile range was used to summarize the continuous variables accordingly. Different types of graphs or charts and tables were used to present the data. Bivariate and multivariate logistic regression analyses were used to identify factors associated with raw milk contamination. The variables in bivariate analysis with In total, 95 participants signed up for this study, and the response rate was 97.9%. The respondents' ages were between 19 and 67 years old, with an average and standard deviation of 38.1 ± 11.4. In terms of sex, most of the research participants 77 (81%) were female. Regarding education status, 84 (88.4%) could not write and read, only 4 (4.2%) went to primary school. On the other hand, 82 (86.3%) respondents were never trained on milk handling, while 74 (77.9%) among the participants in the research did not know the diseases transmitted via milk contamination .Among interviewed participants, the majority of milk producers 72 (75.8%) were using plastic containers, more near half of respondents 52 (54.7%) transported with motorcycles, and 46 (48.4%) transported milk for less than two hours .Regarding hygienic practice observations, approximately 77 (81.1%) participants used containers with poor cleanliness, 45.3% had good personal hygiene, and 41.2% kept the milk under cool conditions .10 (3.7 × 107) CFU/mL, and the mean total coliform count (TCC) was 6.54 ± 1.53 log10 (3.2 × 106) CFU/mL  was 7.57 ± 0.83 log) CFU/mL .Salmonella spp. (1.2%), S. aureus (16.7%), and Escherichia coli (30.7%) (The proportions of TBC- and TCC-contaminated milk were 84 (88.4%) and 75 (78.9%), respectively. Bacteria isolated from contaminated milk were  (30.7%) .Logistical regression analysis has shown that water supply sources for equipment cleaning, knowledge of milk collapse, handwashing practices before milking, and containers of milk were less than 0.25. However, multivariate logistical regression analysis, lack of hands wash before milking (AOR = 2.4 (95% CI: 0.35–16.4)), and unclean milk containers (AOR = 7.47 (95% CI: 0.002–28.64)) was significantly linked to bacterial contamination of raw milk .E. coli and S. aureus were sensitive to ciprofloxacin. The isolated E. coli was highly resistant to ampicillin 19 (79.9%). From bacteria isolates, Salmonella spp. showed high resistance against the drugs tested in the current study  and pandrug resistance of isolated bacteria were 13.2% and 2.6%, respectively .10 (3.7 × 107) CFU/mL. This result was comparable with a reported study done in Yabelo (8.149 log10) [6 CFU/mL) [10 CFU/mL) [10 (3.2 × 106) CFU/mL. This finding was similar to the studies done in Yabelo (6.323 ± 0.028 log10) [10) [10 CFU/mL) [4 CFU/mL) [10 CFU/mL) [In this study, both total bacteria and coliform enumeration were performed by culturing on appropriate media. The total bacterial count mean (TBC) was 7.57 ± 0.83 log9 log10) . In cont CFU/mL)  and Dire CFU/mL) . On the 8 log10) , Ethiopi10) [10) , and Haw CFU/mL) . In cont CFU/mL) , Tanzani CFU/mL) , and EthMilk contaminated by TBC was 88.4%. This result was comparable with the study done in Tanzania (90%) . HoweverEnsercheia coli was 30.7%. This finding was greater than the study conducted in Tanzania (3.5%) [S. aureus was 16.7%, this finding was less than report of study conducted in Zambia (22%) [Salmonella spp., was 1.2%, that was less than reported in a study in Tanzania, Arusha (37.4%) [The prevalence of isolated a (3.5%) , Zambia a (3.5%) , Hawassaa (3.5%) , and Meka (3.5%) . Howevera (3.5%) , Iran (6a (3.5%) , Isiolo a (3.5%) , Tanzania (3.5%) , and Meka (3.5%) . The preia (22%) , two stuia (22%) , and (26ia (22%) , and Hawia (22%) . Howeveria (22%)  and Boreia (22%) . In addi (37.4%)  and Bore (37.4%) . This vaMultivariate analysis showed that milking without washing hands was nearly 2 times more likely to contaminate the milk and using unclean milk containers could contaminate raw milk nearly 7 times higher. This result was similar to studies carried out in Kampala , HawassaE. coli. This finding is comparable with the report of previous studies [Staphylococcus aureus (64.3%) which means it is more comparable with the report of the previous study from Egypt [Salmonella species. This finding was more similar to study done in Bangladesh [Ampicillin was the drug highly resisted by (81.2%)  studies , 36, 37.om Egypt  and Bangom Egypt . Similarngladesh  and lessS. aureus were 28.6%. This result was less than the report from Egypt at 34.8% [S. aureus multidrug resistance was less prevalent among studied milk samples. It is one obstacle to promoting health and life saving conditions for human beings. In addition, the isolated Salmonella species have shown higher multidrug resistance, particularly among commonly available drugs like tetracycline and ampicillin.An overall prevalence of multidrug resistance was 13.2%. The result of the present study was less as compared to report from Jigjiga (55.2%) . Multidrat 34.8% . HoweverThis study enrolled small sample size and also did not identify bacterial resistant gene to antimicrobials. The correlation between phenotype characteristics and genetic MDR has not been evaluated.E. coli 23 (30.7%), Staphylococcus aureus 14 (16.7%), and Salmonella spp. 1 (1.2%). Factors significantly associated with milk contamination were lack of handwash before milking and unclean milk containers. All bacteria isolated showed ampicillin resistance . Resistance against commonly used drugs among the communities might be difficult for medical care. On the basis of the results of this study, the following recommendations are made: the pastoral community must clean the milk containers properly and wash their hands before starting milking. Government and nongovernmental organizations must strengthen cooperation within the sector to use or build safe sources for the community. Regional and national governments must establish a diagnostic center to identify and monitor antibacterial resistance and prevent the animal transmission of pathogens. Doctors should consider drug resistance during the treatment of patients with diseases mediated by milk.The results of this study revealed that raw milk is contaminated by total bacteria count and total coliforms count. The isolated bacteria from contaminated raw milk were


Hip fractures are common in elderly populations and can be life threatening. Changes in healthcare delivery and outcomes for patients with hip fracture treated with intramedullary nails are not well characterized. The objectives of our study were: 1) the characterization of patients treated with the Trochanteric Fixation Nail -Advanced™(TFNA) Proximal Femoral Nailing System or comparable nails (index) and estimate 12-month all-cause readmissions (ACR) and reoperations following index; and 2) the evaluation of 10-year healthcare utilization (HCU) trends for treatment of femoral fractures with femoral nails.This is a retrospective database analysis using the Premier hospital database. All adults with femoral fracture treated with an intramedullary nail, from 2010 to Q3 2019, in the inpatient setting, were identified. Exclusion criteria included patients with bilateral hip surgery and presence of breakage at time of initial surgery. The primary outcome was ACR and reoperation, the secondary outcomes were healthcare utilization metrics. Variables included demographics, comorbidities (Elixhauser Index (EI)), surgical intervention variables and hospital characteristics.Forty-one thousand one hundred four patients were included in the study, of which 14,069 TFNA patients, with average age 77.9 (Standard deviation (SD): 12.0), more than 60% with 3 or more comorbidities (more than 64% for TFNA), 40% with severe or extreme disease severity and one third with severe or extreme risk for mortality. ACR reached 60.1% : 59.6%-60.5%) – for TFNA: 60.0% (95%CI: 59.2%-60.8%). The reoperation rate was 4.0% (95%CI: 3.8%-4.2%) – for TFNA: 3.8% (95%CI: 3.5%-4.1%). Length of stay (LOS) averaged 5.8 days (SD: 4.8), and 12-month hip reoperation was 4.0% (3.8%-4.2%), in TFNA cohort: 3.8% (3.5%-4.1%). From 2010 to 2019: the percentage patients operated within 48 h of admission significantly increased, from 75.2% (95%CI: 74.3%-76.1%) to 84.3% (95%CI: 83.9%-84.6%); LOS significantly decreased, from 6.2 (95%CI: 6.0–6.4) to 5.6 (95%CI: 5.5–5.7) days; discharge to skilled nursing facilities (SNF) increased from 56.0% (95%CI: 54.8%-57.2%) to 61.5% (95%CI: 60.8%-62.2%); ACR rates decreased but reoperation rates remained constant.ACR and reoperation rates were similar across device types and averaged 60.1% and 4.0%, respectively. Ten-year analyses showed reductions in hospital HCU and greater reliance on SNF. Femoral fractures are one of the most common fall injuries in older adults. A total of 325,420 elderly patients were hospitalized for femoral fractures in 2018, of which 67% were female. This higher rate among the female population may be due to underlying osteoporosis [There are many different nail systems available to surgeons, but no difference in outcomes between nails has been found in a 2014 Cochrane review and a recent meta-analysis , 7. MostIn 2015 a novel nail system was brought to market: the DePuy Synthes Trochanteric Fixation Nail Advanced™(TFNA) Proximal Femoral Nailing System. This device is different from other marketed nails as it was designed with a smaller proximal diameter – to allow greater preservation of native bone—but also a far stronger material, to reduce risk of breakage. As expected, a recent study looking at rate of nail breakage from TFNA vs that of other devices revealed no difference, and a 7,979 patients study from the Kaiser healthcare system further confirmed this finding , 9.Wallace et al. used a large hospital billing database to evaluate nail fracture rates in patients treated with TFNA vs similar devices , and created a large dataset of nearly 40 K patients, of which 14,370 were implanted with TFNA.Beyond nail fracture, we were interested in characterizing the demographic and comorbid conditions of patients treated with these nails and estimate the all-cause readmissions and hip-related reoperations across all 40,000 patients. For this study, we used the population identified by Wallace et al.and expanded the analyses to include additional outcomes, specifically all-cause readmissions and hip-related readmissions and reoperations.This is a retrospective study using the patient cohort defined by Wallace et al.  from theThe study used PHD de-identified that cannot be re-identified. As such, the use of the PHD is exempt from broad IRB approval.st, 2010, to September 30th, 2019. The end date was selected to pre-date the COVID-19 pandemic and its impact on patients and hospitals. Exclusion criteria included missingness (missing sex or age), presence of nail breakage concurrent with the first femoral fracture repair surgery, and presence of bilateral fractures, as these patients may be at greater risk for surgical complications.Patients were identified as being > 21 years of age, having an International Classification of Disease (ICD) procedure code specific for femur fracture repair and being treated with TFNA. For contextualization, patients treated with a nail similar in design to TFNA were included and categorized as “non-TFNA nail” patients. These included the Titanium Trochanteric Fixation Nail , Gamma3®  or Natural Nail® , between January 1All patients underwent fracture repair using one of the nails mentioned above. The date of the intervention is defined as the “index”.The following variables were collected at time of index for all patients: demographics , 31 chronic comorbidities as defined by the Elixhauser Comorbidity Index,  presenceThe following outcomes were evaluated: operating room time (ORT) in minutes, length of hospital stay (LOS) in days, discharge destination , 12-months reoperation rates and 12-months all-cause readmission rates. Reoperations were defined as any new hip procedure, whereas all-cause readmission was defined as any new inpatient admission.Two types of analyses were conducted: 1) a descriptive analysis of all variables and outcomes, for each device type; and 2) a longitudinal analysis of patient comorbidity and HCU, over the 10-year period of the study.For the descriptive analyses by device type, counts and proportions were provided for dichotomous and polychotomous variables. Measures of central tendency and spread were provided for continuous variables. All findings were expressed with mean and 95% confidence intervals. A generalized linear model (GLM) was built for each of the 4 distinct population . The GLM model  was used to estimate adjusted length of stay per fracture type.  –13. ReadFor longitudinal analyses over time, counts and proportions were provided for dichotomous  variables. Measures of central tendency and spread were provided for continuous variables . All findings were expressed with mean and 95% confidence intervals.All analyses were conducted using R (version 3.6.3).A total of 41,104 patients were included in the study, 14,069 TFNA, 15,117 TFN, 1,776 Natural Nail and 10,142 Gamma3. Demographic and comorbid data for all patients are shown in Table The majority of patients were female (70%), Caucasian (86%), elderly (average age: 77.9), with nearly 40% age 85 and older. Comorbidities were frequent, with average Elixhauser index above 3 (suggesting more than 3 chronic comorbidity per patient) . Nearly Average ORT was nearly 2 h : 93.9), and LOS averaged 5.8 days (SD: 4.8). Only 14% were discharged to home, of which 7% with home health. Within 12 months of index, nearly 60% patients had a new hospital inpatient admission (ACR). Approximately 4% patients required a hip reoperation. The findings for the TFNA cohort and the cohort of patients treated with other comparable nails are detailed on Table Figures Our study was designed to understand the characteristics of patients treated with intramedullary nails, for proximal femur fracture. Recent studies have demonstrated that TFNA nails had similar revision and breakage risks, compared to other devices , 9. Our The outcomes we analyzed  were fairly consistent across all devices used. Reoperation was uncommon, at approximately 4%. This finding is in line with other papers that reported approximately 5% reoperations after IM nail use . GoodnouOur study has some key strengths: we used 10 years of data and were able to identify more than 40,000 patients, thus generating one of the largest intramedullary nail studies to date. The data we used has very detailed information on the care and hospital episode.Interestingly, we also analyzed length of stay and Elixhauser Index as a function of time. A steady decline in duration of hospitalization has been observed, despite increase in patient comorbidity. This finding may be aligned with current hospital protocols to accelerate recovery and mobility post-surgery, along with the focus on operating on patients early on (within 48 h) of admission. The shortened length of stay did not affect reoperations, which did not change significantly during that time frame.Our study has also some significant limitations: Patients treated within a hospital contributing data to PHD for index, but who change hospitals within 12 months and get readmitted or reoperated elsewhere would not show up as readmission or reoperation in our analysis. Similarly, patient outpatient or nursing home/hospice care is not captured in PHD. As is always the case with database research, we depend on accurate coding for diagnostic and procedures, and could not independently verify diagnoses or procedures. However, it is worth mentioning that PHD does significant data validation and has been used for more than 600 peer-reviewed publications. An additional limitation of our work is that we did not try and match patients across device types to compare them using comparative effectiveness methods. As such, data for TFNA and the non-TFNA cohort are shown separately in a descriptive method.Patients requiring intramedullary nail fixation for treatment of proximal femoral fractures are at high risk for severe conditions and mortality. Readmission was very common, affecting 60% of patients. The reoperation rates, however, were much lower, at approximately 4%. These findings were consistent in the TFNA and the non-TFNA cohorts. The 10-year analysis further highlighted increased patient comorbid conditions with time, but shorter length of stay and greater post-operative reliance on SNF.