The RSM showed that the increment of CaCl2 caused a linear significant  decrease in pH and a linear increase in firmness , hardness (panel scores), and crunchiness. The models for bitterness and fibrousness also included quadratic (CaCl2·MgCl2) and cubic  interactions, which led to areas of minimum and maximum scores around the central points of the CaCl2-MgCl2 and KCl-MgCl2 axes, respectively. In contrast, the increase in the KCl level linearly decreased bitterness scores. Optimisation resulted in a relatively low desirability (0.57) and the selection of a combination that may necessitate further refinement, such as increasing KCl or reducing CaCl2 levels, especially for markets sensitive to bitterness. Interestingly, the overall score and buying predisposition positively correlate with salty, smell, acid, and appearance and negatively with bitterness. Furthermore, PLS-R analysis found that the pivotal attributes influencing overall appreciation were smell and crunchiness while buying predisposition was promoted by crunchiness. Conversely, bitterness had a detrimental impact on these appreciations. Cluster analysis grouped the experimental runs into four categories, with sensory profiles predominantly diverging in bitterness, salty, and kinesthetic characteristics. Ultimately, this study elucidates four distinct sensory profiles that consumers experience.Using response surface methodology (RSM), this study investigates the effect of NaCl substitution (50%) with KCl, CaCl This expansion has extended to countries worldwide, including the USA, Argentina, Perú, and Australia) . This gr6 tonnes .Aloreña de Málaga). Consequently, considering that the green Spanish-style olives constitute around 50% of production, they contribute the most to sodium intake for table olive consumers. In contrast, ripe olives (accounting for 45% of consumption) contribute the least.Traditionally, sodium chloride  has been the main component in brines used for fermentation/storage and packaging . Its preThe link between sodium intake and cardiovascular issues is well-established. Recent reviews have delved into the relationship between sodium intake, the risk of cardiovascular diseases and their dose-response correlation . The metConservolea naturally black olives. Brine levels of 6% and 4% in brines favoured the growth of lactic acid bacteria and prevented off-odour development.In the context of table olives, the interest in reducing salt levels in table olives has parallel consumer concern. However, up to this point, most efforts have primarily focused on the fermentation/storage phases of the most relevant cultivars. Özay and Borcakli  undertoow/w) with a buffer 2, 0.025 M). They found that partial substitution resulted in a product with significantly better texture, colour and high acceptability. Tassou et al. [2 (5 g/L brine) on the mechanical properties and microbial characteristics of cv. Conservolea naturally black olives fermented at different sodium chloride concentrations . The pulp exhibited greater strength and stiffness when the calcium salt was added to the 4 g NaCl/100 mL brine. In Aloreña de Málaga cracked olives [Conservolea natural black olives, using five combinations of NaCl, KCl, and CaCl2. It was found that olives fermented with 4% NaCl and 4% KCl had good organoleptic attributes, while the addition of CaCl2 rendered the product bitter.Kanavouras et al.  conducteu et al.  also invd olives , fermentd olives  researchGordal. Adding CaCl2 reduced the pH, delayed sugar diffusion into the brine, and decreased yeast growth. In this fermentation process, the final product’s Na exhibited a linear relationship with the content in brine, while Ca and K contents followed quadratic models. Furthermore, most sensory attributes were linearly associated with the mineral contents in the brine, except for bitterness, which followed a quadratic model [Sari Ulak olives fermented in brines where NaCl had been partially replaced with KCl, MgCl2, and CaCl2. The preferred olives were those prepared with NaCl, followed by NaCl + KCl and NaCl + MgCl2, whereas those containing CaCl2 were rejected because of their bitter taste.Concerning Spanish-style olives, Bautista Gallego et al.  employedic model . More reic model  examinedNevertheless, a more feasible avenue for salt reduction could lie in the packaging phase. This approach gains traction because the final products usually stabilise via pasteurisation, allowing for lower salt levels . FurtherHowever, such modifications might also have unintended repercussions on the sensory characteristics, making it crucial to thoroughly investigate the potential impacts on consumer-facing products.2, and MgCl2 in the packaging brines of whole (plain) green Spanish-style Manzanilla table olives. The study focused towards examining the physiochemical and sensory properties of these olives. Throughout the experiment, the established salt level recommended by the Trade Standard Applying to Table Olives  was maintained [This research investigated the impact of partial substitution (50%) of NaCl by KCl, CaClintained  to preseThe Manzanilla green olives, which have undergone processing following the traditional green Spanish-style during the 2018/19 season, were provided by JOLCA SA . After fermentation, the olives were stored in a brine solution containing about 10% NaCl as they awaited packaging. For the packaging experiment, a batch of 20 kg of olives (size 240 fruits/kg) was transported to the facilities of the Instituto de la Grasa (IG), CSIC , where they were stored in a cold room until further use. The initial step involved a desalting process at 8 ± 1 °C, aimed at reducing the salt content to 2.5% (g/100 mL moisture of olive pulp), the targeted NaCl proportion for the final product. To this purpose, the olives (20 kg) were immersed in 32.75 L tap water for 72 h, a period considered enough to reach equilibrium based on previous desalting experiments. Before proceeding with packaging, samples of olives and brine in the same proportion as in the desalting containers were withdrawn to confirm the expected equilibrium. Other characteristics of the desalted olives included a pulp proportion of 84.58 g/100 g of olives and a moisture content of 76 g/100 g of olive pulp.2, and CaCl2, ensuring their combined total sum was constrained to 25 g chloride salt mixtures/L brine . The cross-head speed was set to 200 mm/min. The firmness of the olives was the mean of 20 measurements, each of which was performed on one pitted fruit. Shear compression force was expressed as Newtons per gram (N/g olive pulp) [Instrumental hab), the angular component of the polar representation (abh = arctan b*/a*); and the chroma (Ch), the radial component [Ic) (Ic = (−2R560 + R590 + 4R635)/3, where the R values are reflectance at 560, 590, and 635 nm, respectively [Ic and the subjective colour appreciated by a panel in the scale shown in The olive surface colour was determined using a Color-View spectrophotometer  equipped with computer software to calculate the CIE coordinates: L (lightness), a* , and b* . The apparatus was equipped with a C-type illuminant at 10°. Interference by stray light was minimised by covering samples with a box with a matt black interior. Each measurement recorded was the mean of 20 olives’ readings. Other colour measurements were the ratio –a*/b* , habitually used to follow the green colour evolution in vegetables; the hue angle  of table olives [Overall scoring and buying predisposition were evaluated on the same scale according to the global consumers’ appreciation. The responses from the questionnaire were quantified by measuring the distance (in 0.1 cm) from the left anchor. Subsequently, average scores for each descriptor and run were derived, processed, and employed as inputs for further analysis, including mixture design, clustering, and principal component analyses, following the framework described by Hibbert [The sensory analysis was conducted within individual booths under controlled light, temperature, and humidity conditions. The panel consisted of 100 experienced consumers from the Food Biotechnology Department staff. All of them were habitual consumers of green olives, familiar with table olive classification, had between 3 and 10 years of experience and had participated in other sensory studies of table olive presentations . After ae olives . Before e olives . Samplese olives . Only ole olives . The pane olives . Overall Hibbert .2, and CaCl2 mixtures in the packing brines on the physicochemical and sensory attributes of the packaged table olives was systematically examined by applying response surface methodology (RSM). The experimental design was a simplex lattice cubic model, with the process for generating and interpreting these models detailed elsewhere [1, x2, and x3, which correspond to the expected concentrations of KCl, MgCl2, and CaCl2 in the packaging brine after equilibrium, respectively; β and C values are the coefficients to be estimated. The terms which, when added, significantly increased the proportion of variance were retained, and the end resulting model suggested. During the stepwise selection process, the criteria for entering and removing variables were set at p ≤ 0.05 and p ≤ 0.10, respectively. These different levels were motivated by the consideration that a term initially selected at p ≤ 0.05 could still enhance the model performance if retained at p ≤ 0.10. Subsequently, the model’s performance in terms of fit significance (p < 0.05) and non-significance (p > 0.05) of lack of fit was evaluated using ANOVA. Other parameters, such as adjusted R-square, precision, or standard errors of coefficients, were also scrutinised to assess the model quality. Finally, the equations, in terms of actual components (in g/L of the expected equilibrium packaging brine), were deduced and plotted to facilitate the interpretation of the models’ outcomes. The model design was selected and evaluated using Design-Expert v 13.0 .The effect of KCl, MgCllsewhere . This meCluster analysis and PLS regression (PLS-R) were used to study the relationships between the diverse physicochemical parameters or treatments’ correlation. Correlation is a statistical measure that expresses the extent to which two variables are linearly related . It describes a simple relationship without making a statement about cause and effect. Hierarchical Cluster analysis (HCL) is a statistical technique that identifies groups of samples (or attributes) that behave similarly or show similar characteristics and thus quantify the structural elements of the samples or variables . PLS-R iThe fermented plain green olives used for the experiment had an average weight of 4.32  g. They were stored in a brine which, among other characteristics , containfirmness of the olives decreased during the process. However, this decrease was recovered during the subsequent packaging phase and even improved in some runs , the desalting process exhibited a degree of aggressiveness. Consequently, it should be performed carefully.The first target of the work was desalting the stored olives to reach 25 g NaCl/L in the pulp moisture. Beyond the NaCl leaching, a substantial proportion of titratable acidity, combined acidity, and estimated or determined by HPLC, lactic acid was also solubilised into the desalting solution  and in cases where calcium was absent (runs 3 and 8). Regarding moisture content, the packaging step reduced the increase in weight observed in desalting. The resultant moisture content ranged from 72.62 to 76.11 g/100 g olive pulp. Noticeably, at the point of packaging equilibrium, the sum of the titratable acidity and the lactate content from combined acidity (estimated as lactic) closely corresponded with the lactic acid concentration determined through HPLC analysis.Furthermore, packaging also affected the olives’ instrumental firmness, which model exhibited proximity to significance and no significant lack of fit. Despite its limitations, the latter effect warrants consideration due to its impact on table olive quality. In addition to analysing individual models, giving the numerous variables under scrutiny, employing multivariate techniques becomes invaluable for exploring possible relationships between salt combinations and physicochemical characteristics or associating runs with similar features.Nevertheless, the effect of the various packaging brines on the physicochemical characteristics  can be sp-value = 0.0384), significant (p = 0.0384) and had no lack of fit (p = 0.8655). The equation in actual explanatory variable units (g/L) was:The model suggested relating the salt mixtures and pH was linear  of these elements, there is a consistent pH level, regardless of the corresponding concentration of MgCl2.This equation could imply that KCl and MgClalise it A. It tak2 increases or, conversely, increases as the proportion of KCl rises. The diverse salt concentrations have a relatively narrow pH range of approximately 0.3 units. While seemingly modest, this range holds the potential for significant implications on the safety and stability of the product. This effect can be related to the affinity of Ca for the OH- anions, leading to the subsequent release of H+ ions.Moreover, the pH decreases as the proportion of CaClfirmness was significant at p ≤ 0.10 level , slightly higher than the usual threshold, and its lack of fit was not significant . The precision was 4.969 . Although with convenient caution, it may be illustrative of the broad response of this parameter to the use of salt mixtures in table olives. Then, from the food technology viewpoint, the relationship is of great interest. The model was linear , and the equation in actual units was:The model for instrumental 2/KCl relationship is opposed; generally, elevated CaCl2 proportions (with low KCl) correlate with increased firmness, regardless of the specific MgCl2 content associated with a particular ratio. Despite this insight, the challenges encountered during fitting (53% explained variance) imply that firmness changes could also depend on other variables not included in the design. Regrettably, the existing literature provides no pertinent references on this specific aspect.The function structure and the contour lines depicted in the simplex exhibit similarities with that for pH B, suggesIc, L, b*, and Ch values, which experienced notable reductions , smell (p = 0.58), acid (p = 0.43), and saltiness (p = 0.59)) were consistently perceived as similar in all packaged olive runs. However, bitterness, firmness, fibrousness and crunchiness were significantly related . In contrast, the lack of fit was insignificant  to variations of the salt mixtures in the packaged brines.The results from the evaluation sheet  demonstrbitterness, in addition to significant fit, the model had a precision of 14.7, far above the threshold (4.0) considered adequate for navigating the experimental region. The model was quadratic  and took the form:For 2 and MgCl2 emerged as the primary contributors to the perception of bitterness, albeit with a negative interaction effect between them, potentially due to an interference phenomenon. The plot in the simplex   levels and approximately half the proportions of the other two salts. The response surface was a descending hill that progressively broadened as the concentration of K increased. Moreover, a steeper descent is observed along the CaCl2·KCl border than the MgCl2·KCl border. As a result, the graph suggests that CaCl2 might contribute to bitterness more than MgCl2. Additionally, an elevated presence of KCl seems to have a mitigating effect on bitterness perception.CaClstraint) A unveilehardness sensory scores , with a precision of 9.00 . Then, the model was adequate to navigate through the experimental region. Its equation in terms of real components was:2, the salt that most contributed to hardness scoring. When depicted within the simplex . However, it was somewhat complex since it included linear terms , three-way interaction (significant at p = 0.0020), and retained the two-way interactions CaCl2·KCl , KCl·MgCl2  and CaCl2·MgCl2  to make the model hierarchical and adequate for predictions. Then, the equation was:2 content. It ascends to form a broad plateau around the barycenter and extends up to the KCl·MgCl2 boundary. Notably, the surface’s steepest incline is observed at similar concentrations of KCl and MgCl2. Interestingly, this “hill” crest follows a trajectory that closely approximates the bisector of the angle formed by the CaCl2-KCl and CaCl2- MgCl2 boundary and exhibits similar slopes at both sides.The model for  simplex C. The recrunchiness depended on the levels of salts in the packaging brine through a linear model  whose precision was 10 (far above the limit 4). The equation was:Finally, 2. The contour lines were not parallel to the border KCl·MgCl2 (2 vertexes towards the MgCl2 vertex.The more relevant contributor (highest coefficient) was CaClCl·MgCl2 D but som2, and MgCl2 as well as firmness, hardness, fibrousness, and crunchiness while minimising pH and bitterness. Only one suggestion was obtained, resulting in a desirability value of 0.57. This suggestion consisted of using 12.93 g/L of KCl, 6.94 g/L of CaCl2, and 6.38 g/L of MgCl2, respectively. Applying these concentrations, the responses regarding the significant variables would be as follows: pH, 3.36, and firmness, 19.58 N/g pulp. Additionally, the sensory descriptors would reach the following scores: bitterness, 5.11; hardness, 5.84; fibrousness, 6.00, and crunchiness, 5.70. The point of selected concentrations and the predictions for the respective attributes are indicated in each of the previous graphs . The criteria for selecting optimal values for the physicochemical, colour, and sensory characteristics were as follows: maximum concentrations of KCl, CaCls graphs .smell perception was related solely to that of appearance. Acid scoring was associated with salty and firmness evaluations. Bitterness was linked to all kinesthetic attributes, indicating a robust relationship among these characteristic properties. Furthermore, this alignment suggests a pronounced interdependence between these descriptors. Interestingly, the positive association between salty and acid or between hardness, fibrousness, and crunchiness could arise due to a lack of clear differentiation among panellists despite their information before testing. It might stem from inherent difficulties in independently appreciating these descriptors.A first overview of the scores assigned to the various descriptors hinted at the potential close relationship among some. Employing the Pearson correlation analysis is the most straightforward approach to quantifying such relationships (as depicted in 2). These candidates exhibit proximity to the traditional product , displaying high scores for appearance, smell, and salty while lower for kinesthetic sores. Such blends could be promising candidates for initiating salt reduction strategies without significantly modifying consumers’ perceptions.Given the fluctuations observed in the scoring of various runs, it becomes valuable to identify salt mixtures leading to similar features. This approach would facilitate the selection of blends resembling traditional products, the most cost-effective alternatives , or those more suitable for specific markets. The derived dendrogram A,B introbitterness scores  predisposition can offer valuable insights to the industry for aligning its products with consumers’ preferences. PLS-R analysis was employed to explore such a relationship. A four-components model was deemed satisfactory , independent variable , and the overall model quality  appropriate.Establishing connections between sensory attributes, sfactory A, given overall score and buying predisposition with descriptors like salty, acid, smell, and appearance. Conversely, negative correlations are observed with descriptors like bitterness and kinesthetic traits , which are less well-received by consumers. Run 10 was the most appreciated, closely followed by runs 11 and 12. Subsequently, runs 3, 5, 8, and 15 (Control) held favourable positions, possibly due to their association with the traditional product.Projections onto the t1 and t2 axes B reveal overall score and buying predisposition were bitterness  and crunchiness . Moreover, for the overall score, the descriptor smell also held significance. Other descriptors exhibited positive but relatively less impactful contributions. This information then complements the insights from The contribution of each attribute was quantified by its standardised coefficients A,C. Signbitterness, smell, and crunchiness  green table olives. This strategy eliminated the potential risks associated with low salt levels during processing and was exclusively applied to the ready-to-consume, typically pasteurised product. While the initial desalting process caused a noticeable rise in pulp moisture, this effect was subsequently reduced to levels similar to Control. Furthermore, substituting salt-induced modifications in the physicochemical characteristics resulted in a decrease in pH, a slight uptick in titratable acidity, and an enhancement of olive firmness, primarily attributed to the inclusion of CaCl2. The reduced combined acidity observed in the final products was mainly caused by the desalting process, compounded by the dilution effect inherent in the packaging phase. The investigation also reaffirmed that the combined acidity primarily originates from lactic salts. This deduction was supported by the close agreement between the lactic estimation, derived from both titratable acidity and combined acidity as lactate. Additionally, the data revealed that lactic acid concentrations in the pulp moisture closely paralleled those in the brine, indicating that lactic acid is nearly exclusively accumulated in the pulp moisture.During packaging, this study successfully replaced NaCl with KCl, CaCl2 significantly elevated sores for bitterness, hardness, fibrousness, and crunchiness. Conversely, MgCl2 exerted only a slight influence on the sensory descriptors. Notably, the effect of CaCl2 on firmness or hardness  aligns with findings from previous research [bitterness perception. However, beyond the inherent olive bitterness, the exact mechanism by which other elements contribute to bitterness remains elusive.Interestingly, the introduction of salt mixtures did not cause a discernible impact on colour, as the experimental design aimed to replicate the traditional commercial presentations of the product closely. Regarding sensory descriptors, the presence of CaClresearch ,37. In cfirmness is relatively close to maximum values and the selection could be quite appropriate for this attribute. In the case of sensory descriptors, bitterness resulted in somewhat unfavourable treatment, due to the low proportion of potassium, which appears to mitigate this sensation. This happened despite having given bitterness the maximum weight in the selection criteria. Notably, the selection is highly favourable for fibrousness since the chosen point aligns with the maximum scoring region. Furthermore, hardness and crunchiness approach their maximum values. In summary, the selection was generally appropriate, except for bitterness, which was challenging to minimise. To improve consumer acceptance, it might be beneficial to adjust the selected composition towards the centre of the design zone with lower bitterness. This supports the notion that, in the case of multiple variables with various impacts, further refinement may be necessary.In theory, RSM should lead to conditions that produce the best response. However, the situation becomes more complex when several variables with multiple impacts are involved, as in this case where desirability only reached 0.57. Regarding the concentration of salt mixtures for achieving overall optimum results, the selection prioritised KCl at a higher level. This choice is crucial as it can compensate for the substantial loss of potassium during the green Spanish-style olive processing . Calciumbitterness perception, apparently caused by the K cation [firmness of cucumbers was reduced, carrots exhibited a minor increase. However, no bitterness increase was reported.Bansal and Rani  have attK cation . YoussefK cation  studied bitterness in both debittering methods. Despite this effect, the bitterness perception, persistence and aftertaste in the Castelvetrano system olives remained below that of the classic Spanish style, as the latter retained better the characteristic “sweet olives”. Erdogan et al. [2, and KCl to partially replace sodium in table olive production via the traditional Gemlik method. The sensory analysis revealed that mixtures containing only CaCl2 and KCl produced bitter olive products. In contrast, combinations containing 5% NaCl and 5% KCl yielded low sodium olives with satisfactory organoleptic characteristics, aligning with the outcomes of our current research. In recent experiments conducted with the Turkish Sari Ulak cv. cracked table olives [2 alone or in combination with NaCl. Consequently, the precise impact of CaCl2 and KCl salts on sensory characteristics after NaCl replacement remains unclear. Nevertheless, including KCl in brines can yield acceptable low-sodium table olives.Regarding table olives, Ambra et al.  investign et al.  studied e olives , the prefirmness, fibrousness, and crunchiness remained intricate for testers. This challenge, however, is general and has been observed in previous research [crunchiness is valuable and distinguishes certain presentations, such as Aloreña de Málaga [Our study further highlighted a robust relationship among kinesthetic attributes. Nonetheless, despite detailed explanations, discerning between research . Despitee Málaga .acid, salty, and firmness suggests a parallel trend. However, it might also indicate confusion in distinguishing between acid and salty. The outcomes in Gordal olives [bitterness. Conversely, an increase in MgCl2 seems to intensify the perception of bitterness.The positive correlation between l olives . Interes2 was associated with firmness and crunchiness scores, with their peak values observed at minimal proportions of KCl and MgCl2. This correlation between CaCl2 and bitterness and kinaesthetic attributes also finds support in the research conducted by several authors, utilising an enlarged centroid mixture design. These researchers discovered that elevating CaCl2 concentrations enhanced a range of properties, encompassing attributes like Ic, L and b * values, firmness, bitterness, hardness, fibrousness, crunchiness, and salty (negatively), as assessed through PLS-R analysis. Most treatments exhibited healthier properties , resembling commercial products. Our study similarly determined that bitterness was associated with all kinaesthetic attributes. This correlation is logical, given that elevated scores in these attributes may indicate less mature olive or mild lye treatment, leading to more pronounced bitterness in the fruits. Nonetheless, a comprehensive understanding of the changes in bitterness is still in progress, possibly due to the intricate interplay of the various salts involved in the experiments. Then, this aspect remains a subject still requiring further research.In contrast, CaClbitterness had a noteworthy impact on the overall scoring and buying predisposition is outstanding. Conversely, higher ratings in smell and crunchiness corresponded to improved overall scoring and a greater inclination to purchase. The categorisation of runs into distinct sensory profiles through clustering based on sensory attributes can, in turn, guide their choices by processors based on consumer preferences or specific market demands.The identification that 2 and MgCl2 (considered controlled variables) in the packaging brine on the characteristics (the responses) of plain green Spanish-style Manzanilla olives. Applying pasteurisation to stabilise the products reduced any possible safety risk derived from the substitution. CaCl2 exhibited the most significant effect on the final products among the various salts tested. As CaCl2 levels increased in the brine, there was a linear decrease in pH and an increase in firmness, hardness, and crunchiness. The bitterness model incorporated an interaction between CaCl2 and MgCl2, resulting in a minimum point around their respective half concentrations and maximum KCl. Regarding fibrousness, the model revealed significant linear and cubic terms, leading to an area of top scores from the barycenter of the design to the maximum CaCl2 levels, which extended around the central point  of the KCl-MgCl2 axis. This indicates the presence of a saturating effect beyond two-thirds of its content range. In contrast, an increase in KCl was related to reduced bitterness. Contrary to other studies, our results demonstrated that introducing KCl in the presence of CaCl2 and MgCl2 can mitigate the bitter sensation. Furthermore, optimisation resulted in the choice of a combination with relatively low desirability (0.57). This combination should be refined, especially for markets that demand lower bitterness levels, which could be achieved by increasing the KCl content or reducing the CaCl2 level in the packaging brines.Employing RSM, the primary objective of this investigation was to examine the effects of partial (50%) replacement of NaCl with KCl, CaCloverall appreciation were smell and crunchiness while buying predisposition was promoted by crunchiness. Conversely, bitterness had a detrimental impact on these appreciations. The study also facilitated the classification of salt mixtures with similar profiles, which could assist processors in selecting products based on consumers’ demands or specific collective targets.PLS-R analysis indicated that the pivotal attributes influencing


To investigate the relationship between antibiotic exposure and asthma in adults in the United States.Data was obtained from the National Health and Nutrition Examination Survey (NHANES) conducted between 1999 and 2018. A total of 51,124 participants were included, excluding those who were aged < 20 years, female participants who were pregnant, and individuals who did not complete the prescription medications questionnaire and the medical conditions questionnaire regarding asthma status. Antibiotic exposure was defined as the utilization of antibiotics within the past 30 days, categorized based on the Multum Lexicon Plus therapeutic classification system. Asthma was defined as having a history of asthma or having an asthma attack or wheezing symptoms in the past year.The risk of asthma was found to be 2.557 , 1.547  and 2.053  times greater in participants who had used macrolide derivatives, penicillin and quinolones in the past 30 days, respectively, compared with those not using antibiotics. After adjusting for demographic covariates and asthma-related factors, only macrolides derivatives were significantly associated with asthma in the 20–40 and 40–60 age groups. For individuals over 60 years old, quinolones were significantly associated with asthma. The effect of different types of antibiotic with asthma varied in male and female populations. Moreover, higher socioeconomic status, greater BMI, younger age, smoking habits, history of infection, chronic bronchitis, emphysema, and family history of asthma were all identified as risk factors for asthma.Our study indicated that three types of antibiotics were significantly associated with asthma in different subgroups of the population. Therefore, the use of antibiotics should be more strictly regulated. In 2019, it affected as many as 334 million people worldwide, and it continues to represent a major economic burden, in terms of both direct and indirect costs , a cross-sectional survey of a representative US population, which is led by the American National Centers for Health Statistics (NCHS) and the Centers for Disease Control and Prevention (CDC), and has been conducted every 2 years since 1999 . NHANES n = 44,342), did not complete the prescription medications questionnaire (n = 109) and the medical conditions questionnaire regarding asthma status (n = 3). In addition, female participants who were pregnant  were also excluded. A total of 51,124 individuals were included in the study, with 25,170 (49.23%) being male and 25,954 (50.77%) being female. The detailed enrolment procedure is shown in We included participants from 10 survey cycles of NHANES, between 1999 and 2018, and excluded those who were aged < 20 years , and family history of asthma were self-reported by the participants during the interview. Participants were categorized according to age as adult (age 20–40 years), middle-aged (aged 40–60 years), and older (aged > 60 years). Ethnicity was categorized as Non-Hispanic white people, Non-Hispanic black people, Hispanic people, and other. Household socioeconomic status was assessed using the family income-to-poverty ratio (family PIR), which was calculated by dividing household income by the poverty threshold for the survey year . This re2.5.χ2 test.Statistical analyses were performed using the 20-year sampling weights associated with the MECs, according to the NCHS Analytic Guidelines, unless otherwise specified . The samWeighted logistic regression models were used to assess the relationship between asthma and the use of prescription antibiotics. Three models were created: model 1 was not adjusted; model 2 adjusted for age, sex, ethnicity, educational level, socioeconomic status, health insurance status, and BMI; and model 3 further adjusted for smoking status, history of diseases , and family history of asthma. Odds ratios (ORs) and their 95% CIs were used to quantify the relationship between asthma and the type of antibiotic being used. In addition, subgroup analyses according to sex, ethnicity, and age were performed. When creating the model stratified according to sex, all the covariates adjusted for in model 3 were used, with the exception of sex. Analogous processes were used for the subgroup analyses according to age and ethnicity.p value of < 0.05 was considered to represent statistical significance. SAS v.9.4  and R v.4.1.3  were used for the statistical analyses.All the analyses were two-sided, and a 3.3.1.p < 0.001). Out of the 51,124 participants, 16,788 (32.84%) were aged between 20 and 40 years, 16,542 (32.36%) were aged between 40 and 60 years, and 17,794 (34.81%) were aged > 60 years. Non-Hispanic white people were the most common ethnicity (approximately 43.93%) while “other ethnicities,” including Asian, was the least common. Significant differences were found between the asthma and non-asthma groups with respect to most of the parameters assessed. Among the six categories of antibiotics included in the analysis, penicillin had the highest weighted prevalence of use (1.13%) and sulfonamide antibiotics had the lowest (0.31%).As demonstrated in 3.2.The model 1 indicates that, compared to those not using antibiotics, individuals who used macrolide derivatives, penicillin, or quinolones had a 2.557 , 1.547  and 2.053  times greater risk of asthma, respectively. However, after adjusting for demographic covariates and asthma-related factors, but only macrolides derivatives remained significantly associated with asthma , model 33.3.Subgroup analyses were conducted based on demographic characteristics including sex, age, and ethnicity . The mac4.Asthma has been recognized for more than 1,800 years but has become of particular concern during the past four decades, and our understanding of the underlying pathophysiology and the various clinical presentations has developed rapidly. However, it remains one of the most important non-communicable diseases, and causes substantial disability and death worldwide. Therefore, it requires global attention and commitment to lessen its impact. Excessive sensitivity of the airway to external stimuli (hyper-responsiveness) and airway inflammation have been considered to lead to asthma. However, in recent years, the relationship between the microbiota and asthma has become of great interest, and antibiotics have clear effects on the gut and lung microbiota , 25–27. Previous studies have shown that antibiotic use during pregnancy and within the first year after birth increase the risk of asthma in children, but less research has focused on the relationship between antibiotic use and asthma in adults. The present findings provide evidence for an association between antibiotic exposure and asthma in adults. Moreover, we found that macrolide derivatives specifically were associated with asthma, even after adjustment for covariates. Azithromycin, a macrolide antibiotic, is often prescribed to ameliorate asthma and improve the quality of life of patients with asthma –34. HoweChlamydophila, or Mycoplasma are associated with wheezing illnesses in individuals of all ages and may affect the incidence and severity of asthma, and such infections have been hypothesized to have significant roles in the pathogenesis of asthma  and Public service development and reform pilot project of Beijing Medical Research Institute (BMR2021-3); Research Foundation of Capital Institute of Pediatrics (ERB-2023-01). The funders had no role in the study design, data collection and interpretation or the decision to submit the work for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Chronic rhinosinusitis (CRS) is recognized as a heterogeneous disease with a wide range of clinical features, resulting in significant morbidity and cost to the healthcare system. While the phenotypic classification is determined by the presence or absence of nasal polyps and comorbidities, the endotype classification has been established based on molecular biomarkers or specific mechanisms. Research on CRS has now developed based on information based on three major endotypes: types 1, 2, and 3. Recently, biological therapies targeting type 2 inflammation have been clinically expanded and may be applied to other inflammatory endotypes in the future. The purpose of this review is to discuss the treatment options according to the type of CRS and summarize recent studies on new therapeutic approaches for patients with uncontrolled CRS with nasal polyps. Chronic rhinosinusitis (CRS) is a heterogeneous disease with a wide range of clinical features and mechanisms that results in significant morbidity and cost to the healthcare system. CRS affects approximately 3–6% ,2 of theAlthough the 2017 European Position Paper on Rhinosinusitis and Nasal Polyposis (EPOS) guidelines divided CRS into two main phenotypes, CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP) , the newThe EPOS guidelines define CRS as controlled, partially controlled, or uncontrolled, on the basis of objectively determining the degree of subjective symptom reduction, mucosal condition, side effects, need for systemic medications, and need for functional endoscopic sinus surgery.This review aimed to discuss the treatment options according to the type of CRS and, in particular, to summarize recent studies on new therapeutic approaches for patients with uncontrolled CRSwNP.The phenotypic classification of CRS is based on clinically observable features, usually distinguished by the presence (CRSwNP) or absence (CRSsNP) of nasal polyps, which are one of the clinically observable features along with discharge in most patients. Patients are typically classified according to the presence or absence of polyps, determine treatment methods, and determine differences in pathological and biological mechanisms. In addition, sub-classification according to comorbidity is used, and asthma and allergy, aspirin-exacerbated respiratory disease (AERD), allergic fungal rhinosinusitis (AFRS), and CRS with immunodeficiency are representative ,6,7,8,9.CRSsNP is characterized by increased levels of pro-inflammatory cytokines (tumor necrosis factor α and interleukin [IL]-1β), type 1-associated cytokines (interferon [IFN]-γ), transforming growth factor β1, and tissue fibrosis ,11. ConvCRSwNP shows different histological characteristics and prevalence depending on the geographical region. European and American patients show high expression of eosinophilia and Th2 cytokines, and Asian patients show more neutrophilic tissue inflammation ,15. ThesEndotypic classification is based on histological features, such as the presence of neutrophilia, eosinophilia, fibrosis, glandular hypertrophy, and epithelial dysplasia in the early studies ,18,19. CRecently, a structured histopathological classification system was proposed based on a combination of effector cell invasion and tissue remodeling changes . AlthougType 1 inflammatory endotypes are characterized by the expression of T1 cytokines such as IFN-γ and IL-12 produced by Th1 cells, cytotoxic T cells, NK cells, and group 1 innate lymphoid cells (ILC1s). In contrast, type 2 inflammatory endotypes are characterized by the expression of T2 cytokines, such as IL-4, IL-5, and IL-13, produced by Th2 cells, eosinophils, basophils, mast cells, and group 2 innate lymphoid cells (ILC2s). More recently, type 3 inflammatory endotypes have been characterized by the expression of regulatory cytokines such as IL-17 and IL-22 produced by Th17 cells and group 3 innate lymphoid cells (ILC3s).CRSwNP and CRSsNP are not completely dichotomous depending on the presence or absence of polyps and show overlapping signs of inflammation ,30,31. TSeveral studies have reported that the inflammatory endotype of CRS varies geographically worldwide ,33,34,35Recent studies have reported that neutrophilic inflammation may play a role in the pathogenesis of nasal polyps in Asia as well as in the West. In particular, an increase in IL-36 in type 2 CRSwNP and IL-36R+ neutrophils in non-type 2 CRSwNP has been reported in China ,38. ThisIn the case of CRSsNP, type 1 inflammation associated with elevated IFN-γ is dominant, but other follow-up studies have reported heterogeneous inflammatory patterns ,33. TypeTherefore, CRSsNP, like CRSwNP, has very heterogeneous and geographically diverse endotypes ,33,34. TSeveral studies have reported that genetic and environmental factors can also affect the inflammatory endotypes of CRS. Although 87% of CRSwNP patients in the United States had a type 2 inflammatory endotype, second-generation Asian patients residing in the United States had significantly lower nasal polyp eosinophil counts than non-Asians patients ,40. HoweFurthermore, in China, there are differences according to city. In Beijing, 60% of CRSwNP patients showed type 2 inflammatory endotypes, whereas in Chengdu, it was reported in only 20% of cases, suggesting regional variability even in a single country .This suggests that the CRS endotype may vary with geographical location. Further studies on the effects of genetic or environmental factors on the combination of type 1, type 2, or type 3 inflammatory endotypes are needed.Although many studies on treatment methods according to phenotype have been reported, reports on the treatment of CRS according to endotype have rarely been performed. This is because the definition of disease recurrence and treatment success is not clear at the CT scan or endoscopy level, and the time points of therapeutic intervention or evaluation are diverse. Despite these limitations, it is necessary to use appropriate pharmacotherapy, surgical approach, or biological agents according to the endotype to prevent repetitive intervention due to recurrence, reduce the risk of disease progression, and tailor treatment for single patients .According to existing guidelines, antibiotics, such as macrolides and doxycycline, can be considered for the treatment of CRS ,43. HoweMacrolides are characterized by antibiotic properties and immunomodulation by the inhibition of inflammatory cytokines ,45,49 anCorticosteroids are considered a mainstream treatment for CRS with anti-inflammatory properties, and are more useful for suppressing type 2 inflammation than type 1 or type 3 inflammation, suppressing ILC2s, Th2 cells, basophils, and eosinophils. This therapy has been used in the treatment of CRSwNP patients rather than CRSsNP ,63,64,65Topical corticosteroid sprays are used in conjunction with oral medications to treat CRS. Although access to sinus tissue is limited, drug delivery has been improved with high-volume steroid irrigation or steroid-impregnated implants ,75,76,77In CRS, barrier defects can exacerbate inflammation by increasing the antigen access. Furthermore, epithelial barrier remodeling defects or basal cell hyperplasia induced by type 2 inflammation can be partially ameliorated by corticosteroids ,80,81,82AERD is classified as a type 2 sub-endotype with increased production of prostaglandin D2 (PGD2) and cysteinyl leukotrienes . A recenSurgical treatment can be considered selectively if it does not respond to appropriate pharmacological treatment, and the scope of surgery is controversial ,85. StanThe important point in standard ESS is to preserve the sinus mucosa as much as possible while extensively dilating the outflow tract of the sinuses and removing the ethmoid lamella, which can cause obstruction ,90. The Extensive surgery is termed “re-boot” surgery and significant reductions in eosinophilic cationic protein and IL-5 in postoperative nasal secretions have been reported. However, in terms of the endotype, surgical failure is correlated with the presence and intensity of type 2 eosinophilic inflammation and blood eosinophilia ,96,97,98Several studies have reported on the prediction of surgical outcomes according to endotype. In one study, cluster analysis was performed to determine the correlation between endotypes and treatment outcomes. The treatment outcome was worst when asthma was accompanied by type 2 inflammation, in which IL-5, Immunoglobulin E (IgE), and eosinophils were increased in the nasal mucosa . In anotBiologics, a new treatment option for CRS, are increasingly being used mainly in CRSwNP patients and are effective in suppressing type 2 inflammation and minimizing side effects. Several monoclonal antibodies have been approved or are under development for the treatment of CRS, particularly in association with asthma, secondary or exacerbated disease, and recurrence after surgery .Omalizumab is a humanized recombinant DNA-derived IgG1k monoclonal antibody that specifically binds to free IgE in interstitial and blood fluid and to membrane-bound forms of IgE (mIgE) on the surface of mIgE-expressing B lymphocytes . The mecReslizumab and Mepolizumab are monoclonal antibodies that block IL-5, which contributes to the activation, maturation, and survival of eosinophils . IL-5 isBenralizumab is a cytotoxic monoclonal antibody that blocks the IL-5 receptors to eliminate eosinophils. Several studies have reported that it reduces annual asthma exacerbation rates and increases the lung function in uncontrolled asthma. Moreover, a phase 3 trial of CRSwNP was conducted ,115,116.Dupilumab is a monoclonal antibody that blocks IL-4 and IL-13, which are important in type 2 inflammation by binding to the α component of the shared receptor and is approved for the treatment of unregulated CRSwNPs. In two multicenter phase 3 trial randomized controlled trials, dupilumab improved quality of life in patients with severe CRSwNP, as well as reported reductions in nasal polyp size, nasal congestion, and sense of smell . In addiIn a study comparing dupilumab and functional endoscopic sinus surgery (FESS) in CRSwNP patients, both methods were effective in reducing symptoms following the Sino-Nasal Outcome Test (SNOT-22). Furthermore, patients treated with FESS reported greater reductions in polyp burden than patients treated with dupilumab, whereas patients treated with dupilumab reported an improved sense of smell and greater reductions in postnasal drip, cough, and thick nasal drainage . When thn = 3461) comparing monoclonal antibodies and aspirin desensitization (ASA-D) in CRSwNP patients [Different biologics and ASA-D reported significant clinical improvement in patient outcomes in a meta study including 29 randomized controlled trials evaluating eight treatments (patients . In thisAlthough monoclonal antibodies are effective drugs for suppressing type 2 inflammation, there are no guidelines on which biological agents should be used first in patients with type 2 inflammation, because each target mechanism is different. There are reports of the various effects mentioned above, but a direct comparative evaluation for each has not been conducted. However, several recommendations for clinicians were presented at a recent expert board meeting, and dupilumab was reported to have the highest efficacy and objectivity among the currently available monoclonal antibodies . HoweverThe probability of reoperation within 5 years is reported to be 20%, but it is also questionable whether biologics should be used first in patients who have not undergone surgery ,124. AltThe ideal treatment strategy should be determined for each patient; however, in the case of patients with multiple recurrences, the combination of biological agents after planned surgery may be the most effective and practical treatment.CRS was previously classified based on its phenotype; however, as the knowledge of immunopathological mechanisms has significantly increased, it is necessary to establish a new pathway for the treatment of CRS patients based on the three major endotypes of type 1, type 2, and type 3.CRS may be differentiated between other types and type 2 inflammation of immune responses associated with more severe clinical features and comorbidities, such as relapse and asthma. Type 2 inflammation can be found in both the CRSwNP and CRSsNP phenotypes, and is higher in the West than in Asia, but is also increasing in Asia due to rapid industrialization.Although many studies have demonstrated the safety and efficacy of FDA-approved biologics are being reported, there are currently no guidelines for the selection of specific biologics for individual patients. To prevent inefficient treatment and excessive burden on patients, regular clinical monitoring of biological agents and the establishment of appropriate durations and intervals of use are also required.


The aim of this study is to investigate the clinical characteristics and diagnostic and therapeutic methods of bladder metastasis after radical prostatectomy and to improve its diagnosis and treatment.The clinical data of four patients with bladder metastasis after radical prostatectomy were retrospectively analyzed from January 2011 to December 2021. Three cases suffered from intermittent gross hematuria, and only one case was found to have an elevated prostate-specific antigen (PSA) value. Transurethral resection of bladder tumor was performed in four cases, in which one case also underwent resection of urethral mass. Three cases received endocrine therapy, one of which added intravesical instillation and radiation therapy. Another case received chemotherapy based on comprehensive treatment.According to the pathological and immunohistochemical results, three cases were acinar adenocarcinoma of the prostate with Gleason score of 9, and all cases were PSA positive and negative for cytokeratin 7 (CK7) and GATA binding protein 3 (GATA-3). One case was small cell neuroendocrine carcinoma of the prostate and was positive for chromogranin A (CGA), synaptophysin (SYN), and cluster of differentiation 56 (CD56). During the follow-up period of 4 to 13 months, one case was lost to follow-up and three cases were alive.Bladder metastasis after radical prostatectomy is rare, and pathology combined with immunohistochemistry is the gold standard for its diagnosis. Pathological type determines its treatment. Systemic treatment is essential, and local treatment is the most palliative means. Early diagnosis and treatment is significant for better prognosis. The prevalence is rising year by year, and the mortality rate is significant, which poses a serious risk to men’s psychological and physical wellness . One of 22.1Clinical data of four patients with bladder metastases following RP were reviewed at Beijing Chaoyang Hospital, Capital Medical University, from January 2011 to December 2021. Four male patients were aged 61–74 years old with an average age of 66; prostate volume size is 60.00–78.96 ml with a mean of 65.55 ml; bladder masses were discovered 6–41 months after surgery with an average of 26.75 months. All patients had different degrees of lower urinary tract symptoms such as progressive dysuria as the chief complaint, and prostate-specific antigen (PSA) was 60.00, 23.23, 537.80, and 83.00 ng/ml, respectively. The patients underwent ultrasound-guided transrectal prostate biopsy, laparoscopic RP, and regular postoperative endocrine therapy with bicalutamide in combination with leuprorelin or goserelin. The four cases were readmitted with the following complaints: two cases of intermittent painless gross hematuria with clots, one case of intermittent gross hematuria with blood dripping after urination, and one case of progressive elevation of PSA without gross hematuria, with PSA of 0.29, 0.00, 4.29, and 9.36 ng/ml, respectively Table 1.Ultrasound was performed in three cases, and the masses were located in the posterior bladder wall and ranged in size from 1.0 to 3.9 cm, including one case with a hypoechoic area of 5.4 cm × 5.4 cm × 6.1cm near the bladder neck. Enhanced computed tomography (CT) examination was performed in three cases, all of which showed soft tissue shadows in the bladder with varying degrees of bladder wall thickening. One case of magnetic resonance imaging (MRI) revealed iso-T1 and iso-T2 signal shadows with strong signal in diffusion-weighted imaging (DWI) and reduced apparent diffusion coefficient (ADC) value, and tumor recurrence was considered Figure 1All specimens were formalin-fixed, paraffin-embedded, hematoxylin-eosin (HE)–stained, and immunohistochemically stained to label PSA, P504S, high–molecular weight keratin CK34βE12 , keratin CK, GATA binding protein 3 (GATA-3), neuroendocrine markers chromogranin A (CGA), synaptophysin (SYN), and cluster of differentiation 56 (CD56).2.2All four patients were treated with surgery, in which three underwent transurethral resection of bladder tumor (TURBT) and one underwent TURBT combined with urethral mass resection. Two patients received postoperative complete androgen blockade (CAB) treatment with regular oral bicalutamide (50 mg/day) and goserelin (3.6 mg/28 day) or leuprorelin (3.75 mg/28 day) by hypodermic injection. One case received bladder instillation chemotherapy immediately after surgery and CAB treatment as well as external radiation therapy after discharge with the initial radiation dose of DT46Gy/23F and later adjusted to DT16Gy/8F. Another case received systemic therapy based on etoposide combined with cisplatin chemotherapy. The study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Beijing Chaoyang Hospital (2020-science-299-1).3The pathology of the bladder mass was confirmed to be of prostate origin in four patients: three cases were adenocarcinoma with Gleason score of 9, which are all positive for PSA and negative for CK7 and GATA-3; and one case was small cell neuroendocrine carcinoma of the prostate, which was not applicable to the Gleason score but was positive for CGA, SYN, and CD56. Three cases were followed up regularly, and one was lost in 2 months after surgery, with a follow-up time of 4–13 months, averaging 8 months. One received CAB treatment combined with radiotherapy after discharge, and radiation enteritis occurred during radiotherapy that was treated symptomatically. PSA was controlled at 0.01–0.02 ng/ml, and no tumor recurrence was seen in all adjuvant examinations. One case received postoperative systemic therapy based on etoposide combined with cisplatin chemotherapy, and PSA was stabilized at 0.00 ng/ml. However, chemotherapy was ineffective, and the tumor invaded the posterior bladder wall, anterior rectal wall, and pelvic floor muscles as well as developed pelvic lymph nodes, liver, and bone metastases. This patient had recurrent hematuria and urinary retention complicated by moderate to severe hydronephrosis and was in a state of bilateral nephrostomy with poor condition. Another case was treated only with CAB endocrine treatment, and PSA was controlled at around 0.02 ng/ml with no tumor recurrence observed at follow-up. The results of biopsy pathology, surgical pathology, and bladder masses pathology are shown in 4PC is one of the most common cancers and the second most fatal diseases in males with the majority of cases developing in the peripheral zone. In China, only 33% of new cases each year are clinically limited PC, and the rest are locally advanced or metastatic patients with a much worse prognosis than cases in Europe and the United States . PC progThe majority of intravesical metastases are caused by direct invasion of the bladder neck or posterior wall; cystoscopy, systematic biopsy, and immunohistochemistry of the bladder neck may be able to be used to distinguish whether it is direct infiltration or metastasis through the bloodstream. The pathology of bladder tumors is mostly uroepithelial carcinoma, and secondary bladder cancer is rare, accounting for around 2%–13% . PrimaryThe four patients in this research who developed bladder metastases after RP were high-risk PC  4/5), and the risk of lymph node metastasis can range from 15% to 40% . In addiIn terms of diagnosis, PSA value elevates for months or years after RP and reaches biochemical recurrence. It is worth noting that PSA may not be elevated in neuroendocrine PC, but neuroendocrine markers such as CGA, neuronal-specific enolase (NSE), SYN, and/or carcinoembryonic antigen (CEA) may be elevated . ClinicaAs for treatment, patients with bladder metastases and recurrence after RP are already at an advanced stage of the disease process. In principle, systemic treatment is the main method, with local treatment mostly being palliative. TURBT is an option for bladder metastases and hematuria caused by secondary malignant bladder tumors, with the majority being gross hematuria and a few being microscopic hematuria. Persistent hematuria not only can lead to anemia but also can form clots that block the urethra. Studies have shown that, for bladder tumor-derived hematuria, palliative radiotherapy can be used to alleviate hematuria and urinary tract obstruction with definite efficacy and tolerable adverse effects . RadiothIn conclusion, for patients after RP, regular follow-up review should be performed to monitor serum markers such as PSA, testosterone, CGA, NSE, and SYN as well as combined with imaging examinations, clinical manifestations, etc. If bladder masses are discovered, in addition to primary bladder tumors, then secondary bladder tumors should be considered. Cystoscopy combined with histopathology and immunohistochemistry can confirm the diagnosis, and the key strategy is systemic therapy with local treatment being primarily palliative.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.HW, JL, and JW conceived the idea and designed the study protocol. JL, LW, and PQ contributed with provision of study material or patients. HW, SW, and YF-C collected, assembled, and interpreted the data; HW and JW performed data analysis and wrote the manuscript. All authors contributed to the article and approved the final manuscript.


To assess care transition quality and compare it with the clinical characteristics and continuity of care after hospital discharge of COVID-19 survivors.This is a descriptive, observational and cross-sectional study, carried out with 300 patients with COVID-19 who were discharged from a hospital in southern Brazil. The Care Transitions Measure (CTM-15) and question guide about symptoms, difficulties and use of health services after discharge were used. Student’s t-test, Pearson and Spearman correlation were used.The mean score for care transition quality was 74.2 (±18.2). Factors associated with higher quality were receiving care in intensive care (p = 0.001), using non-invasive mechanical ventilation (p = 0.05), using vasopressors (p = 0.027) and having an appointment at the hospital after discharge (p = 0.014). Positive correlated factors were length of stay (p = 0.017), and negative factors were post-discharge symptoms of fatigue (p = 0.001), weakness (p = 0.008), difficulty doing moderate activities (p = 0.003) and how difficult recovery is (p = 0.003).Most participants had a satisfactory perception of care transition. However, aspects such as care plans, referrals and follow-up after hospital discharge require improvements. Brazil is one of the countries with the highest number of infected people in the world; as of January 2023, there were 36,768,677 confirmed cases and 696,603 deaths.The COVID-19 pandemic, caused by the SARS-CoV-2 virus, impacted humanity in large proportions, as it advanced quickly and lethally and highlighted the fragility of health systems in several countries, impacting epidemiological, social, economic, political and cultural aspects. In Brazil, a study identified a COVID-19 hospital admission rate of around 6%, with significant variation in the different phases of the pandemic. Among admitted to hospital patients, 20% require care in the Intensive Care Unit (ICU).Although the majority of patients infected with SARS-CoV-2 are asymptomatic or present mild symptoms, such as fever, rhinorrhea and cough, and recover without the need for hospital admission, some may progress to serious clinical complications, with involvement of the pulmonary, neurological, cardiovascular, urinary, among others. These patients are potential candidates for developing post-intensive care syndrome (PICS) and decreased health-related quality of life. Many need to deal with their comorbidities and may present, during recovery at home, complications related to the disease itself, the decompensation of previous morbidities and the treatment instituted. Furthermore, several consequences persist after discharge, such as fatigue, weakness, dyspnea, neuropathy/myopathy, anxiety and depression,8.While efforts are expended in hospitals to save lives, little attention has been paid to the care needs of survivors returning home. In the context of a pandemic, with social isolation, overcrowded health services and service restrictions, patients may present different post-discharge needs.Discharge from hospital to home is a period of risk for patients, who must deal with new health problems and changes in the care plan, with adverse events, medication errors, difficulties in scheduling appointments and post-discharge examinations, readmissions and use of emergency services. Nurses are central professionals in conducting care transition and managing hospital discharge, being able to enable continuity of care and contribute to comprehensive care,11.Therefore, care transition actions are important to ensure continuity of care for COVID-19 survivors, in order to contribute to the physical, cognitive and psychological recovery and quality of life of affected patients, avoiding readmission in periods when which hospitals are overcrowded. In the context of a pandemic, the challenges are exacerbated, as services are forced to review dehospital admission processes to reduce hospital stay time, increase bed turnover and reduce hospital overcrowding.However, carrying out care transition actions is a complex process, even in the best of circumstances in hospital institutions, with a lack of studies that specifically deal with patients with COVID-19 in Brazil. Therefore, this study aims to assess care transition quality and compare it with clinical characteristics and continuity of care after hospital discharge of COVID-19 survivors.Although care transition is an internationally explored topic, the literature is still emergingThis is a cross-sectional study, in which STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines were followed.The study was carried out from February to November 2021 at a large general university hospital and a reference in highly complex care for patients with COVID-19 in southern Brazil.,14.Patients aged 18 or over, who remained admitted to hospital in an inpatient unit for a minimum period of 48 hours, with a confirmed diagnosis of COVID-19 and discharged from the hospital to their home were included. Patients who did not live in the city of Porto Alegre and the metropolitan region and those who remained admitted to hospital only in the emergency department were excluded. During data collection, if patients had cognitive or communication deficits that prevented them from responding to the survey, caregivers who accompanied the discharge process and recovery at home could be interviewed as a substitute respondent (proxy informant), as carried out in other studiesThe sample calculation was performed using WinPEPI (Programs for Epidemiologists for Windows) version 11.43. Considering an estimated population of 1,250 patients, obtained by weekly mean of hospital admissions for COVID-19 in the hospital studied, a 95% confidence level and a 5% margin of error, a minimum total of 295 participants was obtained. During the data collection period, 729 patients who met the inclusion and exclusion criteria were identified based on weekly reports from the computerized hospital management system. Of these, 353 (48.4%) did not respond to telephone contact in three attempts on different days and shifts of the same week; 20 (2.7%) did not agree to participate in the study; 54 (7.4%) were readmitted at the time of telephone contact; one (0.1%) was institutionalized; and one (0.1%) died after discharge. 250 (83.3%) patients and 50 (16.7%) caregivers responded to the survey., which was adapted and validated for use in Brazil. It consists of 15 items, which are organized into four factors, namely: Health management preparation; Medication understanding; Important preferences; and Care Plan. Answer options are arranged on a Likert-type scale, in which a score is assigned according to participants’ response, as follows: totally disagree = 1 point; disagree = 2 points; agree = 3 points; totally agree = 4 points. There is also an option, “do not know/do not remember/not applicable”, which does not receive a score, as it is not included in the calculation of the final score. To calculate the mean score, according to the authors of the instrument, a formula is applied that transforms the results into scores from 0 to 100, with the higher the score obtained, the better care transition. CTM-15 has been extensively tested and has proven to be reliable, accurate and valid for its purpose,12,14.Data collection was carried out in two stages. The first stage took place from February to October 2021 through telephone contacts, 7 to 14 days after patients were discharged from the hospital. The Care Transitions Measure (CTM-15) was used, developed in the United States to assess care transition quality from patients’ and caregivers’ perspective,5,7 and the authors’ experience. It is noteworthy that, as this is an emerging topic, there is no validated questionnaire to identify symptoms and continuity of care for COVID-19 patients post-discharge. Therefore, a pilot study was carried out with 10 patients, who were not included in the sample. The script is structured and organized as follows: 13 questions about COVID-19 symptoms and difficulties after hospital discharge on a frequency scale that varies from “all the time” to “none of the time”; a question about the perception of the difficulty of recovery at home on a scale with answer options ranging from “not at all” to “extremely”; and seven questions about use of health services after discharge, with answer options of “yes”, “no” and “do not know/do not remember”. The items that deal with symptoms were scored on a scale of 0 to 4, as follows: no part of the time = 0 points; a small part of the time = 1 point; some of the time = 2 points; most of the time = 3 points; and all the time = 4 points. The item asking about how difficult recovery was scored as follows: not at all = 0; a little = 1; moderately = 2; enough = 3; extremely = 4. The remaining items about use of health services were coded: yes = 1; no = 2; and do not know/do not remember = 99.Also, questions were asked about symptoms, difficulties and use of health services after hospital discharge, following a structured script drawn up based on the literatureThe second stage of data collection was carried out in November 2021. Patients’ electronic medical records were consulted to identify sample characterization data, such as sex, age, marital status, race/color, education, comorbidities (according to ICD-10), length of stay in hospital, ICU admission, use of mechanical ventilation, vasopressors and/or dialysis method as well as the presence of emergency service or readmission within 30 days after hospital discharge. It is justified to collect this data after the telephone contact to have a difference of 30 days and obtain the readmission data of the last participant interviewed..Data were exported to an Excel spreadsheet and analyzed using the Statistical Package for the Social Sciences (SPSS) version 21.0. Regarding data analysis referring to CTM-15, the simple mean response for each item was calculated as well as the mean of the total scale and by factor, using the formula indicated by the authors that transforms the means into scores from 0 to 100Regarding sample characterization, symptoms and continuity of care after hospital discharge, quantitative variables were described by mean and standard deviation or median and interquartile range. Categorical variables were described by absolute and relative frequencies.Variable normality was assessed using the Kolmogorov-Smirnov test. Student’s t-test was used to compare means, and Pearson or Spearman correlation was used for the association between numerical and ordinal variables. The significance level adopted was 5% (p < 0.05).The research was approved by the institution’s Research Ethics Committee, under Opinion 4,462,671/2020, in accordance with Resolution 466/2012. An Informed Consent Form (ICF) was used, with verbal consent from participants at the time of telephone contact for data collection and sending an electronic copy of the ICF by text message.In this study, it was observed that 168 (56%) patients were men, 135 (45%) were married, 247 (82.3%) were white, 99 (33%) had completed high school and had a mean age of 51.93 years. (±14.02). The most frequent comorbidities were hypertension , obesity , Diabetes Mellitus , asthma  and cancer . It was identified that 144 patients (48%) required ICU care. A total of 99 patients (33%) underwent invasive mechanical ventilation, and 205 (68.3%) non-invasive mechanical ventilation. A total of 83 (27.7%) patients used vasoactive medications and 15 (5%) used dialysis. The median length of stay in hospital was 13 days (8-26). Only 10 (3.3%) patients were readmitted within 30 days after discharge.Regarding care transition quality at discharge, the mean CTM-15 score was 74.2 (±18.2). Factor 1  obtained a mean score of 77.3 (±19.0); factor 2 (Medication understanding) obtained a mean score of 76.8 (±21.0); factor 3 (Important preferences) obtained a mean score of 76.1 (±18.3); and factor 4 (Care plan) obtained a mean score of 58.4 (±30.9). The item with the highest score was 14 (Understands how to take medications) and the lowest was 12 (Had written list of appointments and tests) .Regarding continuity of care, it was identified that 192 (64%) patients had some contact  with a health professional after discharge. However, 16 (5.3%) received a visit from a community health workers at home; 46 (15.3%) received care at the primary care reference unit; 5 (1.7%) needed emergency care; 36 (12.1%) had an appointment at the hospital’s outpatient clinic; and 30 (10%) had an appointment at a clinic or private office.Furthermore, regarding recovery at home after hospital discharge, it was found that it was a little difficult for 85 (28.4%) patients, moderately difficult for 91 (30.4%), quite difficult for 24 (8%) and extremely difficult for 8 (2.7%). Regarding the bivariate analysis of clinical variables in relation to the mean CTM-15 score, it was identified that caregivers had a worse perception of quality in care transition, with a mean CTM-15 score lower than that of patients . FurtherIn the bivariate analysis of variables relating to continuity of care, there was a weak negative correlation between the CTM-15 score and variables fatigue, weakness, difficulty in carrying out moderate activities and how difficult post-discharge recovery is . FurtherThis study is a pioneer in assessing care transition quality at hospital discharge for COVID-19 survivors and comparing it with clinical and continuity of care characteristics. The results reflect patients’ and caregivers’ opinion about the transition made in the hospital to return home and the difficulties in following up care in health services in the context of a pandemic.,16. ICU admission, use of mechanical ventilation and length of hospital stay rates were higher than the values found in São Paulo and the United States. However, in addition to the differences in the social, economic and health resources of these locations, the studies mentioned collected their data in 2020, while this research was developed in 2021, period in which the Gamma variants circulated, with a higher hospital admission rate, and Delta, with a higher ICU care rate.Findings regarding sex, age and comorbidities are also consistent with other studies with COVID-19 survivors described in the literature. Therefore, it is essential to be alert to the health situation of COVID-19 survivors so that they do not present situations that are harmful to the functioning of the biological system.The findings presented in this study showed that the main symptoms after hospital discharge were difficulty climbing several flights of stairs and difficulties performing moderate activities. Another study also highlighted some persistent post-COVID-19 complications, such as physical exhaustion, dyspnea and fatigue, joint pain, muscle pain or weakness, headache, sleep disturbances, dizziness, anxiety and depression,10. However, it is important to highlight that 7.4% of the individuals contacted in this study were readmitted to the hospital during the data collection period and were excluded, which may perhaps underestimate the readmission rate identified.Furthermore, the percentage of patients who had hospital readmission is lower than that found in investigations with COVID-19 survivors. Therefore, the results of this research indicate a satisfactory care transition quality for COVID-19 survivors, corroborating Brazilian studies with cancer patients that found similar CTM-15 scores. Higher values were found with pediatric patients and lower values with older adults.It was also evident that the majority of participants had a positive perception of care transition at hospital discharge, according to CTM-15. Although the instrument does not have a predefined cut-off point, values above 70 are satisfactory,9,11. An evidence-based model was recommended for use with COVID-19 patients upon discharge from hospital to go home, including several actions that ensure patient-centered care, with preferences and goals taken into account in care plan as well as health education of patients and caregivers for symptom management and treatment compliance. Despite the limitations imposed by the pandemic, such as restricted visits, which prevent the provision of guidance on care for caregivers throughout hospital admission, health teams used communication and information technologies to develop discharge education actions, such as online appointments, educational videos and podcasts, video calls, among others.It can be identified that the factors that deal with health management preparation, medication understanding and important preferences obtained satisfactory scores and with few differences in the means. The literature points out that these aspects are fundamental for a safe and effective care transition. Lack of discharge planning, absence of protocols or systematized counter-referral instruments, little coordination and communication between services are weaknesses reported in Brazil,21. Furthermore, many hospitals do not have a care transition program or institutional documents that guide discharge plan preparation,22. Therefore, discharge planning activities depend on the individual efforts of nurses, which does not happen in the context of a systematized plan. Therefore, the need for strategies to overcome this gap and provide continuity of care after discharge is reinforced.On the other hand, the factor that deals with the care plan and referrals after hospital discharge was assessed as unsatisfactory by participants. Items 12 (Had written list of appointments and tests) and 7 (Had written care plan) received the lowest mean. A similar result was found in a study with older adults. Weak transitions are associated with greater burden on caregivers. Therefore, it is essential to include family members as early as possible in discharge planning, in order to improve care transition quality.It is noteworthy that, in this study, caregivers had a lower CTM-15 score than patients, indicating a worse perception of quality in care transition. In another care context, such as caregivers of patients with stroke sequels, caregivers had difficulties with post-discharge demands, which were related to weaknesses in care transition, considering that patients admitted to the ICU and with a longer hospital stay have a worsening in their health status and quality of life three months after being discharged. However, this study identified that a better CTM-15 score is associated with patients treated in the ICU, using non-invasive mechanical ventilation and vasopressors, correlated with length of stay and indicating that critical patients with longer hospital admission have a better perception of care transition quality. This can be justified by the greater time dedicated by health professionals to prepare the discharge of these patients with long hospital admissions, as they require greater care and attention.The literature is clear in stating that people with compromised health status may have a worse care transition quality.On the other hand, it was found that patients with more symptoms of fatigue, weakness and difficulty performing moderate activities had lower quality scores. Furthermore, the more difficult the self-reported post-discharge recovery, the lower the CTM-15 score. These data suggest that patients with post-discharge difficulties have a worse care transition quality. Therefore, outpatient follow-up after discharge is important to identify difficulties and monitor treatment and home care.It is noteworthy that in this study few patients received care at the primary care reference unit or consulted at the hospital outpatient clinic, clinic or private office after discharge, which demonstrates the need to improve elements of care transition, such as articulation and communication between the hospital and other services in the Health Care Network, in order to promote continuity of patient care. In a study in the United States, it was identified that only 26.8% and 1.6% of COVID-19 survivors had a scheduled appointment in primary care and with a specialist at the time of discharge, respectively. Therefore, despite numerous difficulties in carrying out post-discharge follow-up, it is recognized that follow-up through telephone contact, home visits and/or appointment in primary care can avoid hospital readmission and emergency care,28.In this study, it was observed that those with a hospital appointment after discharge had a better perception of care transition quality. Another investigation found that higher care transition scores were associated with higher rates of follow-up appointment in primary care. Third, it is important to consider that the results of care transition assessment using CTM-15 may have been influenced by participants’ feeling of gratitude for the health service. Finally, questions about symptoms, difficulties and use of health services after hospital discharge are not part of a validated instrument.However, this study has some limitations. First, it was carried out in a single hospital in the south of the country, therefore, it cannot represent the Brazilian reality. Second, 48.4% of eligible patients did not respond to telephone contact, a problem reported to be frequent in COVID-19 patients and is inherently associated with selection biasIn relation to advances in nursing, this study presents findings that point out gaps in the care transition process, such as discharge plan elaboration and primary and secondary care follow-up, which can be strategically worked on by researchers, managers and nurses, in order to advance care transition in Brazil.It was evident that care transition quality for COVID-19 survivors was satisfactory, according to CTM-15. However, aspects that require improvement were identified, mainly with regard to the care plan and referrals after hospital discharge. Most patients had contact with a health professional after discharge, but few received care in the primary care unit, in the hospital outpatient clinic or in a private office. Caregivers had a worse perception of care transition quality than patients. Clinical aspects associated with care transition quality were receiving care in the ICU, using non-invasive mechanical ventilation and using vasopressors. Regarding variables related to continuity of care, patients who had an outpatient appointment at the hospital after discharge had higher scores. On the other hand, it was found that the greater the frequency of symptoms of fatigue, weakness and difficulty performing moderate activities, the lower the quality score. Furthermore, the more difficult the self-reported post-discharge recovery, the lower the CTM-15 score.It is recommended to develop strategies for implementing discharge planning, using a systematized protocol or instrument to prepare an individualized, written discharge plan. The healthcare team should involve patients and their caregivers in developing the plan, providing written instructions and guiding them through necessary referrals for home care. Furthermore, follow-up by telephone or visit is suggested within two weeks after discharge to clarify doubts and monitor difficulties in recovery at home, contributing to care transition.


Conclusions: Advanced age, dominant side, use of the cortical screw as the uppermost screw, and higher plate-screw density were related to proximal screw breakage. When the plate is removed after bony union or delayed union is shown in these situations, the possibility of proximal screw breakage should be kept in mind. Background: Locking a compression plate is a more favorable surgical technique than intramedullary nailing in the treatment of distal femur fractures. This study analyzed the risk factors of proximal screw breakage retrospectively, which was confirmed in the patients with plate removal after bony union. Methods: A total of 140 patients who were fixed by MIPO using ZPLP from 2009 to 2019 were identified. A total of 42 patients met the inclusion criteria and were included. The screw breakage group (12 patients) and the non-breakage group (30 patients) were compared. Results: Approximately 12 (28.6%) of 42 plate-removal patients showed proximal screw breakage. The breakage of proximal screws developed at the junction of the screw head and neck. The number of broken proximal screws averaged 1.4 (1~4). The breakage of the proximal screw even after the bony union is more frequent in older patients ( The incidence of femoral fractures varies in the literature and is reported to be approximately 3–6% ,3,4,5,6.® Periarticular Locking Plate (ZPLP®) for distal femoral fracture. Three experienced surgeons in two different university-affiliated hospitals performed these operations. This was a retrospective study based on medical documents and radiologic images. Between December 2009 and January 2021, 140 patients  aged 15 to 93 years underwent minimally invasive plate osteosynthesis (MIPO) using the ZimmerDistal femoral fractures with AO classification types IIIA, IIIB, and IIIC were included in the list. The exclusion criteria were patients with fixation failure and nonunion, patients fixed by dual plating, and those who did not undergo plate removal surgery.Of 140 patients, 98 were excluded from this study, and 42 met the inclusion criteria. Finally, 12 patients in whom proximal screw breakage was confirmed intraoperatively when the plate was removed were included in the screw breakage group, and 30 patients were included in the non-breakage group . The dem® Periarticular Locking Plate (ZPLP®) was inserted submuscularly and preliminarily fixed with temporary K-wires or drill bits before the insertion of real screws. Skeletal traction below the knee was applied until surgery for the prevention of muscle contracture and fracture site shortening. Patients were positioned supine on the radiolucent operating table under appropriate anesthesia. The lower leg was draped from the iliac crest to the foot for intraoperative assessment of the length, rotation, and angulation. The standard lateral parapatellar approach was used with the knee in 30-degree flexion supported by a rolled operation sheet. An incision was made over the lateral aspect of the distal femur, and the vastus lateralis muscle was retracted to expose the fracture site. With fluoroscopy, reduction of fracture was confirmed with coronal and sagittal views, and the ZimmerBefore definitive screw fixation of the plate, coronal alignment and sagittal alignment were checked again, and definite plate fixation with screws was performed. If the plate contour is not acceptable, which means the gap between the plate and bone is separated, a temporary cortical screw is used to reduce the gap between the plate and bone. The temporary cortical screw can remain or be removed. Rehabilitation started on the second postoperative day, changing from a long leg splint to a Velcro knee brace and continuous passive motion of the hip and knee joints. After discharge, patients were encouraged to perform straight leg-raising exercises. Non-weight bearing was recommended in patients with intraarticular fractures until callus bridging was visualized on plain radiographs; otherwise, tolerable weight bearing was taught. Coronal and sagittal plane angulations were assessed on anteroposterior and lateral full-length femurs, and knee x-ray films were captured immediately after surgery and at every outpatient follow-up visit. Generally, the patients were discharged from the hospital after 2 weeks of operation, which can be followed up every month until union is gained. Preoperative factors include age, gender, fracture classification, fracture configurations, femoral bowing, injury mechanism, time to injury, BMD, BMI, comorbidities, and ASA score. Fracture classification was classified by the AO classification, which defines 33-A as extraarticular, 33-B as partial articular, and 33-C as a complete articular fracture. Fracture configuration was classified into oblique, spiral, and transverse patterns. The ASA Physical Status Classification System was defined as ASA I as a normal healthy patient, ASA II as a patient with mild systemic disease, ASA III as a patient with severe systemic disease, and ASA IV as a patient with severe systemic disease that is a constant threat to life. Intraoperative factors include operation time, plate span width, screw density, screw fixation, or wiring of the fracture site. p < 0.05, and the statistical software used was SPSS 24.0 .Each group’s differences in mean values of continuous data were compared using the Student t-test, and the association of categorical data were examined using the Pearson chi-squared test. The significance level was set at There was a huge incidence of screw breakages. Approximately 12 (28.6%) of 42 plate-removal patients showed screw breakages. All screws were located proximal to fracture sites. The breakage of proximal screws developed at the junction of the screw head and neck. The number of broken proximal screws averaged 1.4 (1~4).An 83-year-old female patient showed multiple screw breakages at the junction of the screw head and neck after the removal of the plate . An 81-yRisk factors were analyzed, distinguishing between preoperative and postoperative factors.2) was 26.0, BMD (T-score) was −2.37, site (Rt:Lt) was 9 to 3, and the average ASA classification was 2.1. 7 patients had an underlying disease; 1 patient was diagnosed with obesity, and 1 patient was diagnosed with diabetes mellitus. In the non-screw-breakage group, the mean age was 55.5, the ratio of sex  was 10 to 20, BMI (kg/m2) was 24.3, BMD (T-score) was −1.87, site (Rt:Lt) was 11 to 19, and the average ASA classification was 1.9. 17 patients had an underlying disease; 2 patients were diagnosed with obesity, and 7 patients were diagnosed with diabetes mellitus  was 2 to 12, BMI , the plate span width was 3.53, the empty holes were 8.1, the wiring of patients was 4, the total number of filled screws was 11.3, the proximal was 4.25, the fracture site was 0.25, and the distal was 6.83. The plate screw density was a total of 0.53, proximal was 0.48, fracture site was 0.16, and distal was 0.96, and there were 6 fixation crossings over the fracture line. In the non-screw-breakage group, the mean operation time was 130 min, the length of the plate was 279 mm, 13.2 mm (hole), the plate span width was 4.93, the empty holes were 8.6, the wiring of patients was 5, the total number of filled screws was 10.7, the proximal was 3.96, the fracture site was 0.40, and the distal was 6.53. The plate screw density was a total of 0.47, proximal was 0.44, fracture site was 0.14, and distal was 0.91, and there were 10 fixation crossings over the fracture line . p = 0.023) and site of operation (p = 0.025) (Rt:Lt). Modifiable intraoperative surgical factors were plate screw density (p = 0.048) and screw configurations (p = 0.039). Non-modifiable preoperative risk factors were age  to lower area moment of inertia . This meImplant removal is not a routine procedure; when the surgeon considers the removal of the implant, screw breakage, and screw head stripping should be considered. These problems are so troublesome during the operation. If the surgeon prevents this problem, implant stiffness and material are also important. Moldevan et al. emphasized torch control during the insertion of screws, which are especially made of weak materials such as titanium alloy .Our study has limitations, such as a small number of cases and not being a comparative study with conventional plate fixation. Additionally, it is a retrospective study. Furthermore, only patients who achieved bone union were included, and cases of non-union or delayed union were excluded. Finally, the current study results showed that the plate length and number of screw holes did not affect the outcomes.The use of the MIPO technique with an LCP for the treatment of distal femoral fractures in the elderly has recently been reported to yield satisfactory results. The 28.6% incidence of screw breakage is a striking finding in this study.Even though LCP showed relatively good results, stress concentration on the screw and plate junction still occurred even after the bony union. Even though the exact risk factors were not figured out in this study due to the lack of cases, the authors suggest that the use of a locking screw at the proximal uppermost is recommended for the prevention of screw breakage after bony union. The stress on the locking screw head and neck junction is higher than that on cortical screws. If the whole screws were locking screws, this stress on the screw head and neck junction could be decreasing. Too high a density of screws also risks factors of screw breakage after gaining bony union. When such a surgical method is chosen, caution is required, as screw breakage occurs when the plate is removed after gaining bone union, despite the significant surgical benefits. Therefore, the surgeon should approach the treatment with caution, considering the possibility of breakage during the removal of the screw when using a cortical screw in elderly patients who underwent surgery on their dominant leg.