Hydroxyapatite (HAP) is the most common calcium phosphate ceramic that is used in biomedical applications, e.g., as an inorganic component of bone scaffolds. Nevertheless, fluorapatite (FAP) has gained great attention in the area of bone tissue engineering in recent times. The aim of this study was a comprehensive comparative evaluation of the biomedical potential of fabricated HAP- and FAP-based bone scaffolds, to assess which bioceramic is better for regenerative medicine applications. It was demonstrated that both biomaterials had a macroporous microstructure, with interconnected porosity, and were prone to slow and gradual degradation in a physiological environment and in acidified conditions mimicking the osteoclast-mediated bone resorption process. Surprisingly, FAP-based biomaterial revealed a significantly higher degree of biodegradation than biomaterial containing HAP, which indicated its higher bioabsorbability. Importantly, the biomaterials showed a similar level of biocompatibility and osteoconductivity regardless of the bioceramic type. Both scaffolds had the ability to induce apatite formation on their surfaces, proving their bioactive property, that is crucial for good implant osseointegration. In turn, performed biological experiments showed that tested bone scaffolds were non-toxic and their surfaces promoted cell proliferation and osteogenic differentiation. Moreover, the biomaterials did not exert a stimulatory effect on immune cells, since they did not generate excessive amounts of reactive oxygen species (ROS) and reactive nitrogen species (RNS), indicating a low risk of inflammatory response after implantation. In conclusion, based on the obtained results, both FAP- and HAP-based scaffolds have an appropriate microstructure and high biocompatibility, being promising biomaterials for bone regeneration applications. However, FAP-based biomaterial has higher bioabsorbability than the HAP-based scaffold, which is a very important property from the clinical point of view, because it enables a progressive replacement of the bone scaffold with newly formed bone tissue. Thus, to mimic the microstructure of bone, composite biomaterials containing polymers  and bioceramics  are frequently synthesized, to potentially achieve greater bioactivity and biocompatibility [Bone is the second most common transplant tissue. The gold standard of bone grafting is harvesting autologous tissue from the iliac crest. However, autograft harvesting is characterized by some drawbacks, such as chronic pain at the donor site, risk of infection, and haematoma formation. In turn, allografts, derived from cadavers or living donors of the same species, carry a risk of immune reaction and the possibility of infection or disease transmission . Thus, ttibility . It is k2/g), reduced bioactivity, and poor solubility, and consequently low bioresorption. Bioresorption is the process in which the biomaterial is gradually degraded in the body over time, either by osteoclasts or by dissolution, to be replaced with the natural host tissue. Thus, “super stable” bioceramics are unable to undergo natural bone remodeling and remain at the site of implantation for years, delaying osseointegration [Synthetic hydroxyapatite (HAP) is the most common calcium phosphate bioceramic that is used in biomedical applications  because of its similar chemical composition  ratio fixed at 1.67) to natural HAP, found in human bone and teeth ,9. HAP cegration ,11,12. Iegration ,14.2+), zinc (Zn2+), silicon (Si2+), strontium (Sr2+), copper (Cu2+), cobalt (Co2+), lithium (Li+), and fluoride (F−), can be substituted into the microstructure of HAP, to improve its biological and physicochemical properties [10(PO4)6F2) has attracted attention in the area of bone tissue regeneration and dental applications. Borkowski et al. (2021) [−, released from FAP-based biomaterials, stimulated the proliferation and differentiation of osteoblasts [− ions may be helpful during osteoporosis treatment, by increasing bone mass [− with F− in the apatite ceramic may lower its solubility, hindering its replacement with newly formed tissue after implantation [Various ions, such as magnesium   showed t21  showeone mass . Neverthantation .Many studies have reported physicochemical analysis and/or biological properties of HAP and FAP . Nevertheless, very few reports have presented a comprehensive comparison of characteristics between HAP- and FAP-based biomaterials, to assess their potential for biomedical applications. In this study, HAP and FAP produced according to Ukraine patent no. 56202, were used for the production of bone scaffolds. HAP- and FAP-based biomaterials were synthesized according to the procedure described in the Polish patent no. 235822. The newly developed and patented synthesis method, combining a foaming agent with freeze-drying, allows the production of highly macroporous bone scaffolds, that may find potential applications in cancellous bone regeneration . A compaThe biomaterials for bone regeneration should possess not only suitable mechanical properties, but should also have optimal porosity, enabling appropriate gas and fluid transport through the whole scaffold, as well as providing sufficient space for the ingrowth of new bone . Thus, tThe compressive strength values determined for the fabricated biomaterials were as follows: 3.01 ± 0.59 MPa for mat_HAP and 2.58 ± 0.75 MPa for mat_FAP . It was 2+ and HPO42− concentrations in SBF, during incubation with the biomaterials. The obtained results were consistent with the EDS analysis of the apatite crystals after a 28-day incubation of the biomaterials in SBF, high uptake of Ca2+ ions by mat_HAP and mat_FAP was observed, which indicated the formation of Ca-rich amorphous calcium phosphates. Xie et al. [2+ ions during the incubation of samples in SBF, may result either from electrostatic interaction between ions and the charged surface of the biomaterial and related apatite nucleation, or from ion exchange events. In turn, mat_HAP and mat_FAP caused an increase in HPO42− ions in SBF, compared to the control SBF, which probably resulted from the dissolution of biomaterials. The results obtained within this study are partly in agreement with the study of Borkowski et al. (2020) [2+ and HPO42− ions from SBF.The ability of biomaterials to form apatite crystals on their surfaces, is called bioactivity. It is a very important feature, since it provides good bonding with the surrounding bone tissue after implantation, facilitating the osseointegration process . The in e et al.  reported. (2020) , who sho2+ ions (degradation product of the ceramic) to the environment after incubation in PBS and HCl solutions. It was observed that the biodegradation of biomaterials in an acidic solution was faster, when compared to the PBS solution, at physiological pH. Surprisingly, mat_FAP revealed a higher degree of ceramic dissolution compared to mat_HAP, in both PBS and HCl solutions, which is not in agreement with the available scientific reports. Generally, mat_FAP released significantly higher amounts of Ca2+ ions compared to mat_HAP, with one exception, i.e., after 30 days of incubation of the biomaterials in the HCl solution, where HAP-based material released more calcium. The performed experiment showed that the fabricated bone scaffolds were prone to slow and gradual degradation, in both physiological conditions and an acidic environment imitating the osteoclast-mediated bone resorption process. It is worth emphasizing, that the slow and gradual biodegradation of implantable materials is crucial from the clinical point of view, because it allows for the progressive replacement of the bone scaffold with newly formed bone tissue [The optimal biodegradation rate of implantable biomaterial is crucial, since it provides space for newly formed bone tissue, contributes to enhanced ion exchange, and protects against the collapse of the scaffold at the implantation site . In thise tissue . Interese tissue ,36. In tApart from appropriate microstructural and physicochemical properties, bone implants should reveal some biological characteristics, such as biocompatibility and osteoconductivity, to accelerate bone tissue regeneration at the implantation site. Biocompatible biomaterials exert cellular response without toxic, immunogenic, or genotoxic effects. In turn, the ability of biomaterials to stimulate cell adhesion, proliferation, and bone extracellular matrix (ECM) synthesis by osteoblasts, is termed osteoconductivity ,38. In tThe number of osteoblasts on the surface of the fabricated bone scaffolds was determined 1, 2, and 3 days after seeding, by total LDH assay c. The peTo guarantee good bone formation in vivo, stimulation of the osteogenic differentiation of cells  is a desirable characteristic of newly developed bone scaffolds. Osteogenic differentiation comprises three main stages, which are characterized by typical markers: (1) cell proliferation , (2) ECM synthesis and maturation , and (3) ECM mineralization  ,39,40. O− ions increased bALP activity. However, it should be noted that the osteogenic differentiation of cells cultured on the surface of bone scaffolds may be affected by various factors, e.g., chemical composition, porosity, topographical features, and stiffness of the biomaterials [ELISA did not reveal statistically significant results in the level of Col I production between the samples, which was confirmed by CLSM images, that presented great deposits of Col I protein on the surface of both biomaterials after 21 days of culture . Late maaterials . Borkowsaterials  investigThe levels of all osteogenic markers, apart from bALP and BSP determined for mat_HAP, were significantly higher for control osteoblasts cultured in a 2D system on a flat polystyrene well, compared to the cells grown on bone scaffolds. However, it should be noted that the cells cultured on the 3D biomaterials had a significantly longer lag (adaptation) phase compared to the 2D culture. Consequently, the cells on 3D scaffolds reveal inferior proliferation, metabolism, and biological activity compared to the osteoblasts grown on flat polystyrene surfaces, when these parameters are assessed at the same time intervals . MoreoveBone scaffolds for regenerative medicine applications are expected to simultaneously promote osteoblast adhesion, proliferation, and differentiation, without induction of chronic inflammation after implantation, within the bone defect. During inflammation, activated immune cells have the ability to generate excessive amounts of ROS/RNS . Within 3, CaO, Ca(OH)2 (for HAP) or CaF2 (for FAP), and NaPO3. The synthesis was performed at a temperature of 350 °C. The Zeta potentials of the synthesized HAP (particle size = 581 nm) and FAP (particle size = 484 nm) were equal to −25.0 mV ± 0.9 and −33.0 mV ± 2.5, respectively [HAP and FAP were synthesized according to the procedure described in the Ukraine patent no. 56202, and with the method described previously , by usinectively . The detectively ,49.w/v) of synthesized HAP (sample marked as mat_HAP) or FAP (sample marked as mat_FAP), were produced in accordance with the procedure described in the Polish patent no. 235822, and with the method described previously [w/v) chitosan , 5% (w/v) agarose , and the appropriate apatite, were suspended in acetic acid solution  and mixed. Next, sodium bicarbonate  was added as a gas-foaming agent. The obtained paste was put in the molds and subjected to heating (95 °C). Then, samples were cooled, frozen, and lyophilized. The resultant scaffolds were immersed in 1% (w/v) sodium hydroxide solution , rinsed with deionized water, and air-dried.Two types of apatite-based biomaterials, containing a chitosan–agarose matrix and 40%  and a scanning electron microscope . The porosity of the biomaterials was determined by micro-computed tomography—microCT , with a voxel resolution of 12 μm. To determine the pore diameter, as well astotal, open and closed porosity, the set of images  was reconstructed into cross-section images of the biomaterials, using the Reconstructor software version 16.1 , and then analyzed using the CTAnalyser software version 1.22 .The compressive strength and Young’s modulus values of the biomaterials (9 mm in diameter and 9 mm in length) were measured using an Autograph AG-X plus  testing machine, under the following parameters: crosshead moving speed of 5 mm/min, load cell accuracy of 0.1 N. The compressive stress was estimated to be 30% of strain.2+) and phosphate (HPO43−) ions. The Ca2+ and HPO43− concentrations were determined by a colorimetric method, using commercially available kits .Determination of the apatite-forming ability of the fabricated biomaterials was performed in accordance with the ISO 23317:2012 procedure, and with the method described previously . Briefly2+ ion concentration (degradation product) by a colorimetric method, using a commercially available kit .An in vitro biodegradation assay was conducted in phosphate-buffered saline solution , mimicking a physiological environment, and in an acidic solution , mimicking the osteoclast-mediated acidification during the bone resorption process. In brief, biomaterials weighing 50 mg ± 1 mg, were immersed in 5 mL of biodegradation solution and incubated at 37 °C, for 30 days. The biodegradation behavior of the biomaterials was determined by measurement of Ca2 in air atmosphere. Osteogenic differentiation experiments were performed by cell culture, in osteogenic medium containing complete culture medium supplemented with 50 µg/mL ascorbic acid, 10 mM β-glycerophosphate, and 10−8 M dexamethasone . During osteogenic differentiation, the cells were cultured at 37 °C, with a 5% CO2 in air atmosphere.Normal human foetal osteoblast cell line  was used, to assess the cytotoxicity, cell proliferation, and osteogenic differentiation on the surface of the fabricated apatite-based biomaterials. hFOB 1.19 cells were cultured in a 1:1 mixture of DMEM/Ham’s F12 medium without phenol red , with 10% foetal bovine serum , 100 U/mL penicillin, 100 μg/mL streptomycin, 300 μg/mL G418 , and maintained at 34 °C, with a 5% CO2 in air atmosphere.In turn, evaluation of ROS and RNS generation in response to the fabricated biomaterials was performed by using immune cells  derived from human peripheral blood . Isolation of neutrophils and monocytes was performed according to the previously described procedure ,51. Indu4 cells/well, and cultured at 34 °C, for 24 h. Subsequently, the medium was replaced with 100 μL of appropriate extracts of the biomaterial and the cells were cultured for the next 24 h. An MTT colorimetric assay  was performed to evaluate cell viability, as described previously [The cytotoxicity assessment was conducted by MTT assay, according to the ISO 10993-5 standard, using extracts of the biomaterials prepared in accordance with the ISO 10993-12 standard. In brief, biomaterial extracts were prepared by immersion of 100 mg of the biomaterial in 1 mL culture medium, and incubation at 37 °C, for 24 h. Culture medium incubated without biomaterial, in polystyrene wells, served as a negative control of cytotoxicity (sample marked as PS_control). The hFOB 1.19 cells were seeded into 96-multiwell plates, at a concentration of 2 × 10eviously . The obt4 cells per sample. After 48 h of culture, cells were stained using the Live/Dead Double Staining Kit , according to the manufacturer’s procedure, and visualized by confocal laser scanning microscope .Additionally, a cytotoxicity assessment in direct contact was performed. The hFOB 1.19 were seeded directly onto the biomaterials at a concentration of 5 × 105 cells per sample. After 1, 2, and 3 days of culture, the number of cells was determined by using the total activity of the lactate dehydrogenase assay , after cell lysis. The LDH assay was performed in accordance with the manufacturer’s procedure. The cell number was estimated from the calibration curve, made for known concentrations of hFOB 1.19 cells. Additionally, after 3 days of cell culture on the surface of the biomaterials, visualization of osteoblasts was carried out, using fluorescent staining and CLSM observation. Before visualization, cells were subjected to fixation and permeabilization, by using paraformaldehyde and Triton X-100 , respectively. Then, the cells were dyed with AlexaFluor635-conjugated phallotoxin , that stains actin filaments, and DAPI , that stains nuclei.The hFOB 1.19 cells were seeded directly onto the biomaterials at a concentration of 1 × 105 cells per sample, and cultured at 37 °C, in an osteogenic medium, for 21 days. Every 3rd day, half of the osteogenic medium was replaced with a fresh portion. To assess the osteogenic differentiation process in vitro, osteogenic markers (type I collagen (Col I), bone sialoprotein (BSP), osteocalcin (OC), osteopontin (OP)) were estimated in cell lysates, using appropriate enzyme-linked immunosorbent assays (ELISAs) . The cell lysates were obtained by two freeze-thaw cycles and then a sonication process, at 30% amplitude, as described previously [The hFOB 1.19 cells were seeded directly onto the biomaterials at a concentration of 2 × 10eviously . The ELIeviously .6, were seeded onto the surface of the fabricated biomaterials, and into the wells of 24-multiwell plates without biomaterials, which served as controls. After 24 h culture of neutrophils and monocytes on the fabricated biomaterials, and after 5 days of culture in the case of macrophages, ROS/RNS generation was determined. Evaluation of superoxide , at a density of 1 × 10 methods ,51, by up < 0.05 and were estimated using unpaired t-test or one-way ANOVA, followed by Tukey’s test (GraphPad Prism 8.0.0 Software).In this study, experiments were performed at least in triplicate (n ≥ 3). The data were shown as mean values ± SD and were evaluated for normal distribution using the Shapiro–Wilk test. Statistically significant results between samples were considered at The results obtained within this study, showed that HAP- and FAP-based bone scaffolds are characterized by a macroporous microstructure, with a network of interconnected pores and compressive strength comparable to cancellous bone. The novel biomaterials are biodegradable under physicochemical conditions (pH 7.4) and in acidic environments (pH 4.5), mimicking the osteoclast-mediated bone resorption process. Moreover, the scaffolds are characterized by high biocompatibility, osteoconductive properties, and have the ability to induce apatite formation on their surfaces, indicating bioactive properties. Moreover, HAP- and FAP-based bone scaffolds support osteogenic differentiation and do not induce generation of excessive amounts of ROS/RNS by immune cells, increasing their potential in biomedical applications.Nevertheless, the performed comprehensive comparative study on HAP- and FAP-based bone scaffolds did not show significant differences between the biomaterials. However, it may be concluded that FAP is a better bioceramic component for the production of this specific bone scaffold (according to Polish patent no. 235822), due to a higher porosity and primary bioabsorbability of the FAP-based biomaterial compared to HAP-containing sample, shown in this study. A good bioabsorbability of implantable materials is a very important property from the clinical point of view, because it allows for progressive replacement of the bone scaffold with newly formed bone tissue. However, it is worth taking into account that the applied production method of the bioceramic-based biomaterials could have affected the physicochemical and biological properties of the apatite component. Thus, FAP is a better bioceramic for the production of this particular bone scaffold. It may reveal different properties after incorporating it as a component in other scaffolds. Therefore, each biomaterial should be tested and considered individually, prior to biomedical application.The methods for the synthesis of HAP and FAP are protected by Ukraine patent no. 56202. The method for the production of the apatite-based scaffolds is protected by Polish patent no. 235822.


Dear Editor,Battles against a critical illness never end even after survivorship, or rather the beginning of long-term hardship patients and families face to restore previous lives. The functional disabilities after ICU stay, or post-intensive care syndrome (PICS), is a physically, cognitively, and mentally devastating state that significantly reduces patient quality of life […] . As prevWe conducted a secondary analysis of previously published point prevalence studies on 3 dates  with the aim of investigating the implementation of the ‘ABCDEF’ bundle and nutrition therapy (defined in Additional file Large potentials to improve ICU care during ECMO were implied, though studies only captured performances on three days in the COVID-19 pandemic under high pressure on ICUs. The importance of pain, sedation, and delirium during ECMO might be relatively acknowledged, reflecting the higher requirements of analgesia and sedation than MV. However, we found an obvious opposite trend against the current recommendations of establishing whole-bundle care. Although no consensus on the optimal timings was set, light sedation, or ‘awake ECMO’, and early mobilization, which showed significant physiological benefits, were also rarely performed despite the relatively long stay in the ICU . ConsideIn summary, large gaps between recommendations for ICU bundled-care and actual implementation were found. This is an urgent wake-up call to all ICU staff towards improving the quality of ICU care for patients requiring ECMO, the most severe and vulnerable patients, for a future of successful functional outcomes Fig. .Fig. 1ImAdditional file 1: Figure S1. Patient flow chart. All 57 ICUs participated in the survey on the 3rd of June, 2020, were included in the 73 ICUs participated in the survey on the 1st of July, 2020. The 73 ICUs participated in the survey on the 1st of July, 2020, and the 135 ICUs participated in the survey on the 27th of January, 2021, could be overlapped but not be able to be identified because of the anonymous nature of the survey response.Additional file 2: Table S1. Definitions of the ‘ABCDEF’ bundle and nutrition therapy.Additional file 3: Table S2. List of participating countries.Additional file 4: Table S3. Baseline characteristics.


To assess the changes in body composition of burn patients through electrical bioimpedance in the phases of response to trauma.a longitudinal observational study, carried out from October 2019 to March 2020. Sociodemographic, clinical, epidemiological, anthropometric and body composition data were collected. Statistical analysis was performed with SPSS, considering a significance of 5%. The comparison between variables was performed using the paired Student’s t test.the sample consisted of 58 adult burn patients, with a mean age of 38.2±12.5 years. The mean body surface area (BSA) with burns was 10.8±7.3%. Nutritional assessment demonstrated a depletion of body weight, Body Mass Index, fat-free mass and muscle mass in the phases of response to trauma (p<0.005).metabolic alterations in the different phases of the metabolic response to trauma led to a depletion of the nutritional status of burn patients of both sexes during hospitalization. In a study conducted in the United States, it was demonstrated that 75% of burn accidents occurred at home and 13% in the work environment, 95% of which were of an accidental nature.Burns are considered a significant public health concern worldwide. The World Health Organization (WHO) has estimated that burn injuries are responsible for approximately 100,800 deaths per year. The Burn Treatment Center in Brasília reported a major involvement of second-degree burns by flames in males (62%) due to domestic accidents.According to the Brazilian Ministry of Health, approximately one million people suffer from burn injuries per year in Brazil,5.Among the main consequences of burn injuries is marked hypermetabolism, which results in significant physiological and metabolic changes, particularly muscle and bone catabolism, hepatic steatosis, an increased risk of infections, insulin resistance, multiple organ dysfunction and sepsis. These changes may cause harmful long-term effects. Body weight and Body Mass Index (BMI) assessment in critically ill patients and after traumatic events is challenging. The initial fluid replacement in response to the acute event, volume resuscitation during hospitalization, the metabolic cascade, the presence of dressings in the affected areas, and edema are factors that make it difficult to measure, analyze, and interpret the nutritional status and body composition of these patients-9.Physiological and metabolic disturbances caused by burns cause changes in the body composition of these patients due to the cascade of inflammatory reactions and accentuation of glycolysis, lipolysis and proteolysis.The use of indirect methods aims at better analysis and interpretation of body changes. Thus, considering the available methods and cost feasibility, we have the use of BIA, a model widely used in clinical practice in hospitalized patients, which offers an easy, quick and practical body compartment and fluid status assessment, enabling the analysis and monitoring of nutritional status and body composition during hospitalizationTo assess the changes in body composition of burns patients through bioelectrical impedance analysis during the phases of response to trauma.o. 466/12. All study participants were informed about the objectives and benefits of the study and subsequently signed the written Informed Consent Form.The study was developed in accordance with national and international standards of ethics in research with human beings, in accordance with the Resolution of the Brazilian National Health Council nThis is a longitudinal observational study, which adopted the STROBE (EQUATOR) as a framework. It was carried out at a large public hospital specialized in the treatment of burns, from October 2019 to March 2020.The patients included in the study were those who had been assessed within 72 hours after admission, aged over 18 years, from both sexes, with a percentage of ≤50% of the total body surface area (TBSA) affected by burns, who were able to walk in order to undergo anthropometric assessment, and with one of the limbs (upper and lower) from the same side of the body (right or left) unaffected by burns so as to assess body composition by bioelectrical impedance.Patients with physical limitations that made it impossible to perform anthropometry, bedridden, amputees, pregnant women and carriers of any implantable device, conditions that influence performance and assessment through electrical bioimpedance, were excluded.st, 2nd or 3rd degree); nature of injury ; place where injured ; affected body surface calculated based on the Lund & Browder map; and affected body areas . Clinical data included comorbidities  and treatment .The sample was given for convenience. Sociodemographic, clinical and epidemiological variables of burns were collected by consulting the clinical records available at the service. Sociodemographic data were collected age, sex , race , origins  and education . Data were also collected on the epidemiology: etiological agent ; burn severity .Laboratory test, anthropometry and body composition assessment was performed at two moments: within 72 hours of admission and on the 7Information was collected from medical records regarding laboratory tests , hematocrit (Ht), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), urea, creatinine, sodium, potassium, albumin, total proteins, C-reactive protein (CRP), total leukocytes and platelets, considering the reference ranges used by the hospital laboratory.et al.. Participants were weighed using an electric Filizola® digital platform scale, with a maximum capacity of 150 kg and a precision of 100 g, and height was measured using a stadiometer attached to the platform scale with a capacity of 1.90 m and 1 mm accuracy. Weight and height measurements were used to calculate the BMI, and the classification used for adults was that proposed by the World Health Organization (WHO).Weight and height were measured according to the original technique recommended by Lohman ®). The analysis required at least 4 hours of liquid and/or solid food fasting. During the procedure, a patient lay in a horizontal supine position, without a watch or any other metallic object. The test included the use of 4 electrodes, 2 placed on the dorsum of the hand and 2 on the dorsum of the foot. The variables collected were total body fat percentage (TBF %), basal metabolic rate , fat-free mass , fat mass , total body water percentage (TBW %), skeletal muscle mass  and skeletal muscle mass index . SMM (Kg) was estimated, for both men and women, from BIA and anthropometric variables, according to the following equation: SMM (Kg) = (height/R x 0.401) + (gender x 3.825) - (age x 0.071) + 5.102, considering height in centimeters (cm), resistance in ohms, sex = 0 for women and sex = 1 for men and age in years. SMMI’s estimate and expression in kg and % followed Janssen recommendation, whereby SMMI (%) = (SMM/weight) x 100) and SMMI (Kg/m2) = SMM/height.Body composition was assessed using tetrapolar bioelectrical impedance analysis (BIA)  . Data were double-entered and validated. Sociodemographic, epidemiological and clinical variables were presented considering absolute and relative frequencies. Continuous variables were tested for normality of distribution using the Kolmogorov-Smirnov test. Normally distributed variables were described as means and their respective standard deviations, and non-normally distributed variables as median and interquartile ranges (p25 and p75). To analyze the comparison of means, the paired Student’s t test and Wilcoxon t test were used for parametric and non-parametric samples, respectively. A significance level of 5% was used to reject the null hypothesis.nd degree burns (89.7%), of an accidental nature (89.7%) in the home environment (70.7%), regardless of gender. Of the 2nd degree burns observed, 42.3% (n=22) had been caused by superheated liquids and 3rd degree injuries by electricity .The sample consisted of 58 adult burn patients, with a mean age of 38.2±12.5 years. According to Burns caused by flammable liquids resulting from violence were observed in 2 male patients (100%), and self-harm was observed in 3 female patients (100%). The mean TBSA with burns was 10.8±7.3%. In terms of the proposed treatment during the hospitalization period, surgical debridements with anesthesia were performed on 56 patients (96.6%), and without anesthesia, on 36 patients (62.1%).In 2 in BMI (p<0.001); 67.3 Kcal in BMR (p<0.001); 0.5% in TBF (p<0.001); 2.3 Kg in FFM (p<0.001); 1.2 kg in SMM (p=0.001); 1.6 kg/m2 in SMMI (p=0.003); 0.5% in SMMI (p=0.001); and an increase of 1.7 kg of FM (p=0.017). Males presented a reduction of 1.9 kg (p<0.001); 0.6 kg/m2 in BMI (p<0.001); 74.5 Kcal in BMR (p<0.001); 0.8% in TBF (p<0.001); 2.7 kg in FFM (p=0.001); 1.2 kg in MME (p=0.021); 1.7 kg/m2 in SMMI (p=0.031); and 0.5% in SMMI (p=0.020). No statistical difference was observed in FM (p=0.362). During the assessed period, there was no change in body water volume distribution.Anthropometric measurements and body composition were compared in the ebb and flow phases according to sex . A reduc. It is known that living conditions based on origin and education are factors that may contribute to a higher risk of accidents. Adult age, elementary education and originating from urban area are factors that may also cause a higher risk for incidents, since these conditions characterize the economically active population and consequently favor greater exposure to risk situations.Victims of burn injuries suffer from clinical, psychological and nutritional repercussions.A higher frequency of burns on the upper and lower limbs may cause a delay in returning to work, thereby bringing about economic and social problems, in addition to reducing an individual’s functional capacity, enabling the development of a chronic health condition.It is known that the evolution of burn patients involves significant alterations in the immune system and biochemical disorders, which affect morbidity and mortality, mainly prompting an increase in endothelial permeability causing the characteristic edema, protein catabolism, leukocytosis and inflammatory processesIn the present study, it was observed that patients’ laboratory parameters during hospitalization remained stable, probably due to the small extent of burns on BSA (10.8±7.3%), thereby avoiding the occurrence of metabolic alterations capable of reproducing major biochemical repercussions.There was a notable decrease in Hb, Ht, MCHC and platelets as a consequence of hemolysis after burn injuries, accentuating the systemic response according to the degree and extent of the injury, associated with fluid replacement with subsequent hemodilution and blood loss, when dressings and debridements were performed. The deviation of protein metabolism promoting the formation of a new skin to the detriment of the formation of new red blood cells may also be contributing to a reduction of these parameters. A significant reduction in serum CRP concentration was also observed during hospitalization, reflecting an improvement in the inflammatory profile associated with wound healing and immunological competence.-21.There are very few studies in the literature that have monitored burn patients’ nutritional evolution due to the presence of fluid disturbances that make it difficult to interpret direct and indirect methods of nutritional assessment. This is the first study conducted in Brazil to assess burn patients during the different phases of the metabolic response to trauma and using BIA. Furthermore, it is also the first study to use the SMM and SMMI estimation formulas recommended by the European consensus on sarcopenia for the population with burns,22-24. Biolo et al. demonstrated that the vast majority of the body’s protein reserves reside in skeletal muscle, hence, a state of hypercatabolism primarily compromises muscle mass. In fasting burn patients, there is a 1.5-fold increase in the rate of muscle protein synthesis and a 1.8-fold increase in the rate of protein depletion, which encourages a negative nitrogen balance due to a marked loss of skeletal muscle mass.One of the main metabolic characteristics after burns involves increased resting energy expenditure (REE), thermogenesis and loss of muscle mass. Hypermetabolism causes a 3 to 10-fold increase in serum cortisol concentration, which may persist for up to three months after the injury. Furthermore, cortisol inhibits glucose uptake and glycogen synthesis by skeletal muscle, thereby directly and/or indirectly causing muscle mass losset al.. A significant reduction in body weight and BMI was observed in both sexes (p<0.001). However, the BMI parameter is not sufficiently sensitive to indicate precise changes in body compartments, especially in the population with burn injuries due to the presence of fluid disturbances. Thus, regardless of the nutritional diagnosis by BMI, the use of indirect methods should be considered in order to assess changes in the body composition of these patients during hospitalization.Nutritional status is a relevant factor in patients’ healing and clinical evolution after burns. In the total sample of the present study, the BMI indicated a higher frequency of eutrophy , followed by overweight , thus corroborating the study by Silva . This condition may even be of even greater concern due to being bedridden during hospitalization, thus inhibiting the synthesis of skeletal muscle mass.Our data on body composition assessment with the BIA method have indicated a reduction in BMR, FFM, SMM and SMMI in the first phase of the metabolic response to trauma. This phase includes glycolysis, glycogenolysis, gluconeogenesis and proteolysis, increasing protein degradation mainly in muscle tissue for energy supply and tissue synthesis, which thereby explains the depletion of FFM, SMM and BMR in these patients. Furthermore, there is a marked lipolysis, aided by the increase in cortisol and consequent increase in the release of free fatty acids (FFA) for energy supply-28.Increased levels of FFA and systemic lipids are commonly associated with a hypermetabolic response. Studies have reported significant lipid alterations and high triglyceride levels in burn injuries with increased negative effects.After a marked lipolysis, there is an increase in FFA, which may be used by cells to generate energy or esterify in the liver in the form of triglycerides. However, these esterified triglycerides in the liver are released as low-density lipoproteins (LDL) into the plasma. Therefore, the reasons that explain this increase in triglycerides in burn patients include FFA synthesis stimulation as a product of accentuated lipolysis and by high levels of plasma glucose, increased production of LDL and low plasma levels of high-density lipoproteins (HDL)-29. Previous studies have reported central fat accumulation in burn patients due to intense hypermetabolism.In the present study, it was observed that, during their entire hospital stay, patients evolved with an increase in FM. This may be explained by the increase in lipid cycling after burns, regulated by catecholamines, corticosteroids and cytokines, followed by an increase in triglycerides and FFA, suggesting greater decomposition and re-esterification of fats, aided by insufficiency of FFA carriers2) that occurs during hospitalization-16.FFM is a good conductor of electrical current compared to FM. Thus, patient hydration may influence FFM levels. In turn, SMM better characterizes the gross muscle mass of burn patients, since it is not directly influenced by hydration. It should be noted that TBW did not vary significantly between the assessments. This suggests that increased fluid replacement did not influence the loss of FFM, since its depletion occurred during hospitalization. Studies have reported a linear relationship between height and muscle mass, while body weight has a curvilinear relationship with muscle mass. Thus, height is the best factor for correcting muscle mass in these patients, justifying the significant reduction in SMMI (Kg/m. Moreover, there is an increase in triacylglycerol degradation, causing an excess of fatty acids and glycerol in the blood, whereby these substances are consequently stored in the adipose tissue in the form of triglycerides. Therefore, in these patients, metabolic and physiological changes during fasting directly contribute to a reduction of food intake, muscle mass depletion and lipogenesis.The application of recurrent fasting for surgical debridement with anesthesia implies an increase in catabolic hormones, an inflammatory response and a secretion of catecholamines and glucagon, accentuating catabolism and muscle depletionSome limitations should be mentioned, such as the sample size and the formulas used to estimate patients’ SMM and SMMI, which are not specific for the population with burn injuries, thereby suggesting the development and future validity of specific equations for populations that suffer from fluid disturbances.The study can contribute to better targeting the assessment interprofessional analysis of the burned population, seeking to identify early the impairment of the nutritional status of these patients, in order to contribute to plans of interprofessional actions and treatments to improve quality of life, with consequent reduction of health costs.nd degree burns, superheated liquids and mainly affecting the upper and lower limbs. The higher frequency of elementary school education and originating from urban areas, thus characterizing the economically active population, reinforces the need for preventive measures based on educational guidelines regarding simple changes in small daily, household habits in order to reduce incidents.In conclusion, it was observed that most burn injuries occurred accidentally in the home environment, involving 2The use of direct and indirect methods of nutritional assessment in patients with severe fluid disturbances may help in providing a better analysis and interpretation of nutritional status evolution. A depletion of body weight, BMI, FFM and muscle mass was observed in the phases of the metabolic response to trauma. This indicates the importance of monitoring changes in the body compartments of these patients so that interprofessional strategies may be adopted early to assist in attenuating metabolic stress and reducing morbidity and mortality.


The proposed triplexer has very low insertion losses of 0.12 dB, 0.09 dB, and 0.42 dB at the first, second, and third channels, respectively. We achieved the minimum insertion losses compared to previous triplexers. Additionally, the common port return losses (RLs) were better than 26 dB at all channels.Global concerns regarding environmental preservation and energy sustainability have emerged due to the various impacts of constantly increasing energy demands and climate changes. With advancements in smart grid, edge computing, and Metaverse-based technologies, it has become apparent that conventional private power networks are insufficient to meet the demanding requirements of industrial applications. The unique capabilities of 5G, such as numerous connections, high reliability, low latency, and large bandwidth, make it an excellent choice for smart grid services. The 5G network industry will heavily rely on the Internet of Things (IoT) to progress, which will act as a catalyst for the development of the future smart grid. This comprehensive platform will not only include communication infrastructure for smart grid edge computing, but also Metaverse platforms. Therefore, optimizing the IoT is crucial to achieve a sustainable edge computing network. This paper presents the design, fabrication, and evaluation of a super-efficient GSM triplexer for 5G-enabled IoT in sustainable smart grid edge computing and the Metaverse. This component is intended to operate at 0.815/1.58/2.65 GHz for 5G applications. The physical layout of our triplexer is new, and it is presented for the first time in this work. The overall size of our triplexer is only 0.007 λ Growing global concerns about environmental preservation and energy sustainability have arisen due to the multiple impacts of climate change and the increasing demand for energy. To meet the rigorous requirements of industrial applications, sustainable energy solutions need to be developed. In the last ten years, there has been a significant increase in the number of low-cost, diverse sensors that are connected to the internet in smart cities . These sMicrostrip passive devices such as dual-channel diplexers , multi-cg2 which is the best compared to the previously reported triplexers. Moreover, having a wide fractional bandwidth (FBW) is an advantage in the design of triplexers. Our triplexer achieves an FBW of 15%, which is the best compared to the previous works. Additionally, the proposed triplexer is a low-loss microstrip device which makes it suitable for energy harvesting applications, while the majority of the previous triplexers had higher insertion losses at all channels than ours.None of the mentioned triplexers could reduce the size significantly, while our triplexer has a compact size of 0.007 λIn this paper, we present a design of a very compact low-loss microstrip triplexer for GSM and 5G applications. The design steps include mathematically analyzing a basic resonator, designing three bandpass filters (BPFs) using the analyzed resonator, and integrating the BPFs. For the utilized resonator, the scattering matrix was calculated. Then, the conditions for reducing the loss and tuning the resonance frequency were obtained simultaneously. Using the presented mathematical analysis, the resonator behavior was determined. Therefore, the proposed structure could be easily optimized. To verify the advantages of this work, a comparison with previously reported microstrip triplexers was set.(1)First, we propose an approach that combines the concepts of sustainable smart grid edge computing and Metaverse technology to achieve a sustainable concept;(2)Second, we describe how 5G-enabled IoT completes the digitalization process for sustainable smart grids and Metaverses, emphasizing that it is crucial for creating a sustainable infrastructure;(3)Third, we analyze the requirements for nodes in the edge layer and the edge node and highlight the need for highly efficient IoT operations with 5G. We suggest that achieving this efficiency is essential for the success of the framework;(4)Finally, we design, manufacture, and measure a new GSM triplexer that is specifically designed for 5G-enabled IoT. A GSM triplexer is a device that separates signals in the radio frequency range, and our device is particularly efficient for 5G-enabled IoT. Despite its compact size, the performance of the proposed triplexer is good as it has very low insertion losses.In this paper, we make several important contributions in the areas of sustainable smart grid edge computing, metaverse technology, and 5G-enabled IoT.g2, compared to previous works. Additionally, the proposed triplexer exhibits very low insertion losses of 0.12 dB, 0.09 dB, and 0.42 dB at the first, second, and third channels, respectively, and outperforms previous triplexers. Furthermore, the common port return losses (RLs) are better than 26 dB at all channels, indicating the effectiveness of the proposed approach.Growing global concerns about environmental preservation and energy sustainability have arisen due to the multiple impacts of climate change and the increasing demand for energy. To meet the rigorous requirements of industrial applications, sustainable energy solutions need to be developed. Smart grid technology, which incorporates advanced communication and computing capabilities to optimize energy consumption and distribution, holds promise in achieving this objective. However, traditional private power networks may not suffice to meet the demands of modern industrial applications. Therefore, researchers are investigating innovative technologies such as edge computing and Metaverse-based platforms. The 5G technology is well-suited for smart grid services due to its distinct features such as high reliability, low latency, and large bandwidth. The progress of the 5G network industry heavily relies on the Internet of Things (IoT), which will act as a catalyst for the development of future smart grids. Despite the advantages of these technologies, there are still significant challenges to address, such as the optimization of the IoT for sustainable edge computing networks. To address this challenge, this study presents the design, fabrication, and evaluation of a highly efficient GSM triplexer for 5G-enabled IoT in sustainable smart grid edge computing and the Metaverse. The proposed triplexer is intended to function at 0.815/1.58/2.65 GHz for 5G applications and has the smallest overall size, 0.007 λThis paper is divided into six sections to discuss various aspects of 5G-enabled IoT and GSM triplexer design. As smart grid technology has advanced, it has become apparent that traditional private power networks are no longer sufficient to meet the demanding requirements of industrial applications . This isIn recent years, there has been an enormous growth in micro-electromechanical systems (MEMS) technology, leading to an increase in the use of low-cost sensors with advanced communication and data processing capabilities in the traditional Internet of Things (IoT). These wireless sensors require less power and can perform multiple functions, making them ideal for various applications such as health monitoring, security, environmental monitoring, industrial sensing, disaster prediction and diagnostics, and context-aware applications such as smart homes .In this regard, the integration of 5G-enabled IoT in edge computing smart grids and the Metaverse can indeed enhance the efficacy of energy management. Smart grids can use sensors and meters to collect real-time data on energy consumption and generation by different nodes, which can then be analyzed and used to optimize the distribution and utilization of energy ,30. The These advancements have led to the emergence of 5G-enabled IoT, which connects a wide range of objects to the internet including smartphones, PCs, smartwatches, and cars. With the use of 5G technology, these objects can transfer and process large amounts of data quickly and efficiently, making them more useful and practical for a variety of tasks. Additionally, the use of 5G-enabled IoT has given rise to new applications and services, such as autonomous vehicles and remote healthcare, that were previously not possible . The birTo increase the processing speed and reliability of the system, the proposed framework also incorporates edge computing layers. These edge computing layers are embedded in the system and provide additional computational resources closer to the consumers, reducing latency and increasing the overall system efficiency. The framework also includes a triplexer, which enables seamless communication between the different types of consumers. The triplexer is a component that allows the system to support multiple modes of communication simultaneously, such as voice, data, and video. This allows the various types of consumers to communicate with each other seamlessly, without the need for additional infrastructure or communication protocols. The use of 5G-enabled IoT technology ensures that communication between physical nodes and edge layers is secure and useful. Moreover, 5G technology offers high-speed data transmission, low latency, and reliable connectivity, making it an ideal choice for supporting the proposed framework.Additionally, the figure illustrates how generators in the smart grid network are controlled by instructions produced in the metaverse. The metaverse is a virtual space where users can interact with each other and digital objects in a simulated environment. By integrating the metaverse with the smart grid network, the proposed framework can manage complex systems in a holistic manner, allowing for more efficient and effective control of the overall system. In summary, C) effectively achieve the bandpass frequency response. First, we needed to generate a passband by introducing a novel resonator. To create a passband, we needed an equivalent structure with some inductors and capacitors. Using the coupled lines was a good choice because the equivalent LC of them can create a passband. To save the size, they can be embedded in two open loops. Finally, we reached the basic structure of the proposed resonator in a, lb, lc, and ld were replaced by the inductors La, Lb, Lc, and Ld, respectively. The equivalent of coupled lines was approximated, while in the more accurate model we have to increase the number of inductors and capacitors.The proposed resonator and its approximated LC circuit (a circuit which includes inductors and capacitors) are presented in Z1, as follows:It is possible to simplify the LC circuit by replacing the equivalent impedance of internal coupled lines ω is an angular frequency. For an easy calculation, we have to use some approximations. We can set only the middle capacitor in the equivalent model of main coupled lines. Although the accuracy of this model was a little lower, we inevitably used this approximation to simplify very complex mathematical calculations. The simplified LC circuit is presented in Z2 can be calculated as follows:In Equation (1), Z3 can be obtained easily using the following equation:Additionally, the impedance 2Z in Equation (3), Z3 is changed as follows:By substituting Z4) is:Finally, the equivalent impedance between input and output ports  is defined by:The ABCD parameters of the proposed resonator and S-parameters are obtained using the following equation :(6)A=D=1S11|2 + |S21|2 = 1, the condition for decreasing the loss can be found as follows:For a lossless, passive two-port network |ω) is in GHz, and the inductors are in nH. Accordingly, we can use the following approximations to simplify Equation (5):The simulation results show that the coupling capacitors are usually small values in fF (or pF). Our target angular frequency (The following result will be obtained by combining Equations (8) and (9):Based on Equations (8) and (10), it can be written as:c inductor is less important in setting the resonant frequency and achieving low losses. However, without approximation the value of this inductor would appear in Equation (11). In total, by using the last equation it is possible to simultaneously adjust the resonance frequency and apply the necessary conditions to reduce losses. Using the analyzed resonator, three BPFs were designed. According to Equation (11), the values of inductors and coupling capacitors can be obtained for a predetermined angular frequency. Having the values of the inductors makes it possible to find the dimensions of the transmission lines using the Richards transformation . Anotherg × 0.045 λg = 0.007 λg2, where λg is the guided wavelength calculated at 0.815 GHz.By integrating the BPFs, our triplexer was obtained as presented in 1, l4, l5, w1, and w3, while the lower channel is only impacted by changing l2. By increasing the physical length l2 and width w3, some harmonics will appear. Increasing the length l3 leads to the appearance of harmonics created by BPF3. Also, decreasing l6 results in the appearance of the harmonics. However, the width of w2 should be neither large nor small, to suppress the harmonics.Hence, the frequency response as several functions of significant lengths and widths is depicted in A flowchart for summarizing the triplexer design steps is shown in 10 MHz to 20 GHz measurement range;76 dB dynamic range;Accurate swept power measurements;40 dB directivity bridges;Four independent display channels;Limit testing built in;Save/recall setup and data;Direct plotter or printer output.The simulation results were extracted from Advanced Design Systems (EM simulator). The measurement and simulation results were in good agreement where the measured results were obtained by an HP8757A network analyzer. HP8757A is a 20 GHz Network Analyzer from Agilent Company. It is a microprocessor-based receiver capable of making scaler (magnitude only) reflection and transmission measurements over a frequency range determined by the external detectors used. It has the following features:O1 = 0.815 GHz, FO2 = 1.58 GHz, and FO3 = 2.65 GHz, with three low insertion losses of 0.12 dB, 0.09 dB, and 0.42 dB, respectively. The first and second channels were wide, with 20% and 27.2% fractional bandwidths (FBW1 and FBW2), respectively. The common port return losses in the first, second, and third channels was better than 26.6 dB, 38.4 dB, and 27.1 dB, respectively. The measured losses were a little more than simulations due to copper and SMA losses. As shown in S23, S24, and S34) were better than −20 dB. The RLs from ports 2, 3, and 4  were better than 27.7 dB, 45.1 dB, and 21.7 dB, respectively.The measured insertion losses were 0.39 dB, 0.21 dB, and 0.66 dB at the first, second and third passbands, respectively. The measured isolation between the output ports was better than −19.5 dB. The measured common port return losses at the lower, middle and upper channels were better than 24 dB, 35.1 dB, and 24.1 dB, respectively. From these results, it is clear that the proposed triplexer has high performance compared to the previous designs. A photograph of the fabricated triplexer is presented in 1, IL2, and IL3 were the insertion losses at the first, second, and third channels, respectively. The RLs at the first, second, and third channels were presented by RL1, RL2, and RL3, respectively. Since the design of a microstrip triplexer is more complicated and difficult than microstrip filters and diplexers, there are not many recent triplexers to compare with our design. The actual performance gain in the triplexer design depends on various factors including novel structure, designing process, compact size, low losses, high isolation, wide FBW, and agreement between the mathematical analysis, simulation, and experimental results. Therefore, it is fair to compare the performance of triplexers with the parameters presented in our comparison table. These are the same parameters that the previous works mentioned to compare and show their superiority.To show the features of this triplexer, we compared it with previously reported microstrip triplexers in terms of size and performance. The comparison results are presented in g2, while no triplexers with a size smaller than 0.01 λg2 have been reported yet. We obtained this achievement without any negative effects on the frequency responses. As shown in The comparison results show that our triplexer had the most compact size, with the lowest insertion losses at all channels. Moreover, the widest FBWs and the best common port return losses at the first and second channels were obtained in this work. According to the comparison Table, the size of our proposed triplexer was only 0.007 λCurrently, the Metaverse is considered a trending topic in numerous research areas and is currently the fastest-growing sector in high-tech ,37. The g2, making it significantly smaller than reported microstrip triplexers, which typically could not achieve a size less than 0.01 λg2. Despite its compact size, our triplexer has good performance, with very low insertion losses at the first, second, and third channels, which are 0.12/0.09/0.42 dB, respectively. The common port return loss (RL) at the first, second, and third channels is good, and better than 26/38/27 dB, respectively. To achieve this good performance, we designed a resonator consisting of three pairs of coupled lines that were mathematically analyzed to tune the resonance frequency and reduce losses. We also optimized the physical dimensions of the triplexer to further improve its performance.In this respect, we designed and evaluated a triplexer component that is super-efficient and intended for use in 5G-enabled IoT in sustainable smart grid edge computing and the Metaverse. The proposed triplexer is designed and fabricated to operate at the specific frequencies of 0.81 GHz for the low-band 5G applications and 1.58 GHz and 2.65 for the mid-band 5G applications. One of the key features of our proposed triplexer is its small size, which is only 0.007 λOverall, the proposed triplexer is super-efficient and small in size, making it an attractive option for use in 5G-enabled IoT in sustainable smart grid edge computing and the Metaverse. The good performance of our triplexer makes it suitable for use in a variety of applications where efficient signal transmission and low losses are critical.This 5G infrastructure, particularly 5G-enabled IoT, has great potential to enhance the profitability and reliability of investors and power companies, contributing to greater sustainability and facilitating the transition to cleaner energy sources. Although there are still various ways in which IoT devices can be deployed, they can expedite the energy industry’s positive transition and contribute to reducing carbon emissions.Ensuring an uninterrupted energy supply to consumers is a significant challenge for the power grid, one which is influenced by various factors such as interferences, internal faults, unpredictable incidents, weather patterns, and energy consumption . To overThe integration of 5G-enabled IoT in edge computing smart grids and the Metaverse can improve energy management. Smart grids can gather real-time data on energy consumption and generation from different nodes through sensors and meters. These data can be analyzed to enhance energy distribution and utilization . The useThe integration of IoT technology in smart grids offers boundless opportunities. This allows utility providers to connect with consumers seamlessly through precise communication, leading to increased productivity in a simplified manner. The IoT facilitates social collaboration, resulting in swift decision-making and a reduced total cost of ownership of applications. This interconnectivity is enabled through mobile phone communication. Cloud technology provides significant financial benefits, especially when considering the total cost of ownership of a particular solution, including its impact on services, operating expenses, and purchase costs. By investing in improving their product services, companies can secure stable pricing for the duration of a contract period without having to worry about hidden costs .In summary, microstrip components such as the suggested Global System for Mobile Communications (GSM) triplexer provide a range of advantages for sustainable IoT in smart grids and the metaverse. The most significant advantage of microstrip technology is that it only requires a two-layer board, with all components mounted on a single side, making it the most cost-effective RF circuit board solution ,40. As aMicrostrip components are an ideal option for building a sustainable 5G network and can significantly improve the resilience of the network in case of failures. Their cost-effectiveness, efficient design, and precise control over characteristic impedance make them a reliable solution for RF circuit board design, especially in high-frequency applications such as 5G networks.Microstrip components have become a popular choice for sustainable smart grid edge computing due to several benefits. These components are energy-efficient, consuming less power than traditional components, which is important in edge computing, where power consumption is a significant concern. In addition, microstrip components have a small form factor, making them suitable for use in edge computing devices that have limited physical space. Furthermore, microstrip components are highly customizable and can be designed to meet specific requirements, which is important for smart grid edge computing systems that need to meet specific performance criteria. Lastly, microstrip components can be produced using low-cost manufacturing techniques, making them more affordable than traditional components, which can help to reduce the overall cost of smart grid edge computing systems and promote sustainability. Overall, microstrip components offer several advantages that make them well-suited for sustainable smart grid edge computing, promoting energy efficiency and reducing environmental impact.g2 = 555 mm2.The increasing need for energy and the effects of climate change have caused concerns about energy sustainability and environmental conservation worldwide. The development of smart grid technology has shown that traditional private power networks are inadequate for meeting the demands of industrial applications. The growth of the 5G network industry will heavily rely on the Internet of Things (IoT) for further progress, which will drive the expansion of future smart grids. This advanced platform will not only provide the communication infrastructure for smart grid edge computing, but will also include Metaverse platforms. Therefore, optimizing the IoT is essential for creating a sustainable edge-computing network. This article introduces the new design, manufacturing, and evaluation of an ultra-efficient GSM triplexer specifically created for 5G-enabled IoT in sustainable smart grid edge computing and the Metaverse. The proposed resonator is examined to acquire a scattering matrix and identify the condition for minimizing loss. The triplexer presented in the paper operates at 0.81 GHz (for low-band 5G and GSM), 1.58 GHz (for mid-band 5G), and 2.65 GHz (for mid-band 5G). The advantages of this triplexer are low insertion and return losses at all channels, wide fractional bandwidths at the first and second channels (20% and 27.2%), and a compact size of 0.007 λ


SEMA7A, GATA4, LHX2, SOST, and CTLA4, regulating the Wnt signaling pathway. The relationship between identified DMGs/hub genes and patient survival time uncovered a two-component mixture of AFT regression model. The genes NMNAT2, ZFP42, NPAS2, MYLK3, NUDT13, KIRREL3, and FKBP6 and hub genes SOST, NFATC1, and TLE4 were associated with survival time in the most aggressive form of the disease that can serve as potential diagnostic targets for early CRC detection.Colorectal cancer (CRC) involves epigenetic alterations. Irregular gene-methylation alteration causes and advances CRC tumor growth. Detecting differentially methylated genes (DMGs) in CRC and patient survival time paves the way to early cancer detection and prognosis. However, CRC data including survival times are heterogeneous. Almost all studies tend to ignore the heterogeneity of DMG effects on survival. To this end, we utilized a sparse estimation method in the finite mixture of accelerated failure time (AFT) regression models to capture such heterogeneity. We analyzed a dataset of CRC and normal colon tissues and identified 3,406 DMGs. Analysis of overlapped DMGs with several Gene Expression Omnibus datasets led to 917 hypo- and 654 hyper-methylated DMGs. CRC pathways were revealed via gene ontology enrichment. Hub genes were selected based on Protein-Protein-Interaction network including  Despite being the second leading cause of cancer-related deaths, less attention has been paid to early detection due to the fact that patients do not adhere to invasive screening tests such as colonoscopy3. It has been shown that epigenetic alterations in solid and liquid biopsies can be used for early detection and thus prognosis and effective treatment4. DNA methylation at CpG sites (5mc) is an epigenetic mark that regulates gene expression through transcriptional silencing5. Aberrant DNA methylation plays a crucial role in the pathogenesis and progression of CRC and has emerged as a promising diagnostic marker for the disease6. In particular, aberrant DNA methylation can impact genes where their inactivation may exacerbate tumor formation through the induction of genomic instability or by directly silencing the methylated gene7.Colorectal cancer (CRC), the third most common cancer worldwide, is a group of diseases characterized by genetic and epigenetic changes8. While the genes SEPT9, NDRG4, and BMP3 are FDA-approved for CRC10, there are many other genes such as APC, SFRP1, TFPI2, and VIM that have not yet been approved8.Much research has been done to develop comprehensive panels of biomarkers based on DNA methylation that can facilitate accurate diagnosis of CRCIn order to detect and validate genes that are potential CRC biomarkers, the following steps should be taken. Firstly, a panel of biomarkers must be developed using accurate statistical methods with a deep understanding of the underlying biology of the disease and the molecular mechanisms that drive them. Secondly, the significant biomarkers must be validated via in silico validation using several other datasets; and thirdly, the effectiveness of top candidate biomarkers in improving patient health should be verified using survival models. Lack of adequate precision in each of the above steps leads to misleading conclusions. Among others, two issues affect precision: removing genomic positions with missing values or low read-depth and ignoring the heterogeneity of DMG effects on survival times.11, aging12, and hazardous behaviors13 , among others. Such factors are often ignored by most studies when predicting methylation profiles. In addition, methylation data always suffer from heavy missing values that can affect subsequent analyses. For instance, 68% of CpG sites have missing values in at least one sample in our dataset  associated with CRC and validating them, it is crucial to identify their underlying signaling pathways that regulate gene expression24. In a recent study25, the Cox-LASSO survival model was used to account for a larger set of biomarkers but ignored the heterogeneity of covariate effects. To the best of our knowledge, none of the studies have taken into account the heterogeneity of DMG effects on survival time. To address this problem, one may use the sparse estimation method in the finite mixture of accelerated failure time (AFT) regression models26. Prior to this step, it is common to screen the number of genes to a manageable magnitude. This process can be done by selecting the top highly correlated genes with survival time of the patients using the correlation-adjusted scoring method27.In the next step, the relationship between identified DMGs and the survival time of CRC patients should be evaluated. Most studies employ a limited panel of biomarkers selected through conventional univariate Cox proportional hazard regression models and overlook the potential effects of the rest of the biomarkersThis study aimed to identify CRC-related DMGs to serve as potential biomarkers for early detection by including all the available information in the data and avoiding the exclusion of any genomic position. To this end, we acquired a high-throughput DNA methylation dataset which consists of patients with CRC and healthy individuals. Information on age, history of smoking, and drug abuse was also collected. A description of the data is provided in 2In this section, we outline the data analysis process we followed to detect DMGs, hub genes, and their effects on the survival time and enriched pathways of CRC. 28. This discovery dataset contains the methylation read counts and read-depth for each CpG site captured by SureSelectXT Human Methyl-Seq with 101 read length that generates 57 to 76 million Illumina sequencing reads per subject. Between 88.5% to 89.8% of sequenced reads were mapped to either strand of the human genome (GRCh37/19). The average number of times each CpG has been sequenced per sample was between 19X and 24X. The sequencing information of the subjects is presented in To identify methylation-based CRC biomarkers, information on 6 patients with adenocarcinoma of CRC and 6 normal males was obtained. Two groups were matched based on age, and family history of cancerDMCHMM pipeline29 to identify CpGs with differentially methylated patterns between CRC and normal discovery samples. We specifically did not remove any position with missing information or low read-depth. The missing information was imputed using DMCHMM via hidden Markov models14. Significant differentially methylated cytosines (DMCs) were selected based on the FDR threshold of 0.05. DMCs were aligned to the human reference genome (GRCh37/19) using the UCSC Genome Browser (https://genome.ucsc.edu). A gene whose promoter was mainly hypo- or hyper-methylated was classified as hypo- or hyper DMG, respectively.We utilized the 30, GSE7771831, GSE10176413, GSE42752,32 GSE4868433) were extracted from the Gene Expression Omnibus . Of these datasets, a total of 212 CRC and 242 normal mucosa tissue samples were selected based on setup conditions to minimize the confounding effect of other variables. These datasets have provided valuable insights into the molecular alterations that occur in CRC, and their findings have implications for the diagnosis and treatment of this disease. For the analysis of methyl array profiles of validation sets, the GEO2R (http://www.ncbi.nlm.nih.gov/geo/geo2r/) web tool and the Limma R-package were used. A probe was considered differentially methylated if its adjusted p-value was less than 0.05, and the absolute of log2 of methylation fold change was greater or equal to 1. The differentially methylated probes were aligned to the human reference genome (GRCh37/19) using the FDb.InfiniumMethylation.hg19 package. In the last step, we compared the lists of DMGs based on the validation sets and our discovery samples to identify consistent hypo/hyper-methylated genes across different populations and platforms.To validate our result, several methylation profiles (GSE53051Cytoscape software (Version 3.9.1). Next, we employed the Molecular Complex Detection (MCODE) algorithm to uncover densely connected substructures within the network. The MCODE score must be greater than 3 and the minimum number of nodes must be 4. In order to identify key hub genes within the network, we used the cytoHubba plugin and considered the degree of centrality as a parameter.In order to investigate the Protein–Protein-Interaction (PPI) network and module analysis, we utilized the ‘Search Tool for the Retrieval of Interacting Genes’ (STRING) database. We set the interaction score threshold to 0.4 to screen for high-confidence interactions and visualized the resulting network using the https://david.ncifcrf.gov/). Gene ontology (GO) terms and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways were considered significantly enriched if the p-values were less than 0.05 and the q-values were less than 0.1. The visualization of the identified GO terms and KEGG pathways were done with the clusterProfiler, pathfindR, and ShinyGO (http://bioinformatics.sdstate.edu/go/) packages.To gain insight into the biological mechanisms that are driving CRC and prioritize identified DMGs, we performed functional and pathway enrichment analysis using DAVID  is subject to right-censoring and the covariates are the centered, log-transformed average methylation of identified DMGs/hub genes.To explore the relationship between identified DMGs and survival time, the DNA methylation profiles of 521 samples were obtained from The Cancer Genome Atlas (TCGA) networkanalysis  and lite27carSurv package. Next, we used the fmrs package35 to study the relationship between the survival time of the patients and the remaining DMGs using the smoothly clipped absolute deviations (SCAD) penalty26.It is common to screen the number of genes prior to analysis in case of a large number of identified genes. To this end, we applied a correlation-adjusted score method using the 3We identified 2,691,019 DMCs between CRC and normal groups of the discovery dataset while adjusting for the potential confounding effect of smoking history or drug abuse. Of these identified DMCs, 1,985,557 positions were hypo-methylated and 705,462 CpGs were hyper-methylated in CRC vs normal samples. The heatmaps in To explore the genomic location of the DMCs, we analyzed their distribution across different regions and summarized the results in Given the potential significance of promoter methylation in cancer development and progression, we focused our subsequent analysis on DMCs located on gene promoters, which encompassed 268,978 CpGs. These CpGs resided on 3,406 gene promoters, of which 1,394 were hyper-methylated and 2,012 were hypo-methylated. The list of DMGs is available as supplementary material.To verify the robustness of identified DMGs, we performed a cross-platform procedure with DMGs identified in selected GEO datasets as depicted in The analysis of robust DMGs in CRC utilizing the DAVID tool yielded a variety of enriched biological processes, molecular functions, and cellular components. Specifically, the hyper-methylated DMGs were found to be principally involved in ‘cell fate commitment’, ‘regionalization’, ‘embryonic organ morphogenesis’, ‘embryonic organ development’, ‘pattern specification process’, ‘animal organ morphogenesis’, ‘tube morphogenesis’, ‘tube development’, and ‘neurogenesis’ in the context of biological processes . EnricheKIT, SEMA7A, BDNF, MEF2A, LDB2, GATA4, LHX2, SOST, CTLA4, NKX2–2, TLE4, BMP5, NFATC1, ZFPM1, DPYSL2, and ITGA2B that showed a close interaction with other node proteins were chosen as hub genes , SOST (p = 0.027), NFATC1 (p = 0.017), and TLE4 (p = 0.0061) being upregulated, had a significantly lower probability of survival. However, this conclusion is based on univariate analysis, and the effect of other genes and the potential heterogeneity of DMG effects were ignored. We reanalyzed these data by accounting for the heterogeneity of DMG effects and obtained different results as follows.We performed a survival analysis using the TCGA-selected samples to investigate the association of selected hub genes with the survival time of CRC patients. Based on We studied the relationship between the average promoter methylation of the identified DMGs and the survival time subject to right-censoring by accounting for the heterogeneity of gene effects using an independent set of 521 TCGA CRC samples. To this end, we screened all the 1571 candidate DMGs using the correlation-adjusted regression survival scores to obtain the list of top candidate covariates. This process led to the selection of 95 highly correlated DMGs. These genes were also dysregulated in the TCGA samples. In addition, 4 hub genes that were related to the survival time of CRC patients were added to the list of covariates.HLA-F, MMP2, MT1A, RFPL4B, SIX6, ZFAT, BCKDK, AMOTL1, ADCY10, KCNK10, STAU2, and NOC4L were not related to survival time in either of the components. These findings demonstrate the heterogeneity of DMG effects in CRC data and justify using a sparse mixture modeling rather than a univariate one. In addition, the DMGs with active promoters in Component 1 can be considered as biomarkers for CRC prognosis.Our analysis yielded a two-component mixture of AFT regression model. The estimated gene effects on the survival time are given in 436. As DNA methylation changes are closely associated with cancer, their role in CRC biomarker detection in the early stages of cancer is of great importance. Although many CRC biomarkers have been detected in the literature, only a few are used in practice. Our findings resulted in identifying new biomarkers for CRC which can be used for diagnosis and prognosis.Colorectal cancer is one of the deadliest cancers in the world. Given that early stages of CRC do not display symptoms, proactive screening is the only viable approach to identify the diseaseSEPT9, NDRG4, VIM, APC, SFRP1, SFRP4, and SFRP5,37 are the most important CRC-related ones. We also explored CRC-related hub genes. Fourteen functional modules that may play important roles in the early detection of CRC were highlighted and the sub-network of hub genes KIT, SEMA7A, BDNF, MEF2A, LDB2, GATA4, LHX2, SOST, CTLA4, NKX2–2, TLE4, BMP5, NFATC1, ZFPM1, DPYSL2, and ITGA2B was extracted. These hub genes were flagged as potential diagnostic and therapeutic targets for CRC in our analysis.We identified 1,571 DMGs most of which have been previously studied in the literature. Among them, NKX2–2, KIT, BNDF, and TLE4 in CRC and its sub-types41, their roles in increasing CRC risk, tumor progression, and targeted therapy have been investigated. For instance, MEF2A42 and BMP543 increase the CRC risk. Up-regulation of the expression of ITGB7 and ITGA2B has been found to be significantly associated with death by sodium butyrate-induced CRC organoids44. Moreover, some studies46 have shown effective treatments by targeting CLT-4 and LDB2n.In addition to the diagnostic role of our identified hub genes such as LHX2, ZFPM1, and DPYSL2. For instance, the differences in tumor and corresponding adjacent benign tissues regarding LHX gene expressions have been investigated47. However, contrary to our findings, they did not find any statistical differences for LHX2 and LHX3 genes. Furthermore, the upregulation of ZFPM1 was revealed in molecular high-risk patients with cytogenetically normal acute myeloid leukemia48, yet its diagnostic value in CRC has not fully been confirmed49. SEMA7A is also one of our selected hub genes that play a key role in several cancers including pancreatic, breast, and lung cancers53. However, there has been less attention on the role of SEMA7A in CRC. Further investigation is required on our flagged DMGs.There is a rich literature on the contribution of some of our identified hub genes in CRC and less evidence in support of some others such as SOST, an identified hub gene in our study, plays a vital role in inhibiting the Wnt signaling pathway by binding to the Wnt co-receptor, LRP5/6, and preventing its activation54. Therefore, decreased SOST expression could lead to an increase in Wnt signaling, promoting CRC cell proliferation, migration, and survival. Another identified hub gene is TLE4 which is involved in the negative regulation of the canonical Wnt signaling pathway. Only a few investigations provided evidence of TLE4 upregulation in CRC biopsies, partially through regulation of the JNK/c-Jun pathway55. Moreover, recent studies that focus on the NFAT signaling pathway showed a promising strategy for CRC treatment56.Although there are many mechanisms that drive CRC, only a handful of them has been discovered in past studies. As researchers continue to genotype large panels of CRC tumors, it can be expected that additional new pathways of CRC carcinogenesis will be revealed. NMNAT2, ZFP42, NPAS2, MYLK3, NUDT13, KIRREL3, and FKBP6 had an effect on the survival time of the patients. The relation between some of these DMGs and survival time has been previously reported57. On the other hand, there are a few discoveries regarding other genes. For instance, significantly higher expression of NMNAT2 in CRC tissues compared to normal ones have been found, yet this gene was not a prognostic factor for overall survival58. Note that, while the hub genes SOST, NFATC1, and TLE4 were associated with survival in the univariate Cox model, they were only associated with survival time in the most aggressive form of the disease in our study.Heterogeneity is one of the key features of genomic data. Specifically, there is evidence of the heterogeneity of DMG effects on the survival of CRC patients in the literature and in our dataset. The finite mixture of AFT regression model is a plausible method to uncover such intangible heterogeneity. Our analysis suggested a mixture of two-component mixture of AFT regression model in which patients were separated into two subgroups based on their vital status. In this model, almost all of the deceased patients were classified into the most aggressive form of the disease (Component 1). In Component 1, 83 DMGs including