Myofascial pain syndrome (MPS) is a common chronic pain syndrome that may affect quality of life, daily living activities, and psychological status. Ultrasound (US)-guided rhomboid intercostal block (RIB) is a recently defined plane block and used for chronic pain such as postmastectomy syndrome and MPS. Our aim was to evaluate the efficacy of US-guided RIB for the management of pain, quality of life, physical disability, and patient satisfaction in MPS.In this prospective study, between February and March 2021, a total of 30 patients who applied with the diagnosis of MPS, were included. The patients received US-guided RIB. Pain intensity was evaluated using a numerical rating scale (NRS) at pretreatment, and just after the intervention, at day 1, and 1, 2, 4, and 6 weeks after the intervention. At pretreatment and 6 weeks after treatment, Short Form-36 Health Survey (SF-36) for health-related quality of life, Neck Disability Index (NDI), and patient satisfaction were evaluated.There was a statistically significant decrease in average NRS immediately after treatment, at day 1 and week 1,2,4, and 6 compared to the pretreatment (p < 0.0001). The average SF-36 scores advanced at 6 weeks after treatment. There was a statistically significant reduction in mean NDI scores throughout the follow-up period (p < 0.001).Our study demonstrated that RIB had improved neck function, physical and mental quality of life, and patient satisfaction in MPS. Therefore, we think US-guided RIB could be an alternative treatment modality in patients suffering from MPS. Myofascial pain syndrome (MPS) is a common chronic pain syndrome accompanied by sensory and motor symptoms as well as autonomic phenomena. It is characterized by the presence of myofascial trigger points defined as palpable, hyperirritable bands or nodules. Contractile activity of myofascial trigger points and nociceptor stimulation responding to pathological processes in the muscle fascial layer leads to myofascial pain . The paiWith the increasing use of ultrasound technology in regional anesthesia and pain medicine, newly defined interfascial plane blocks (IFB) have become more popular. Ultrasound (US)-guided rhomboid intercostal block (RIB) is a thoracic plane block recently defined by Elsharkawy et al. in a patient presenting with multiple rib fractures . RIB invCurrently, a variety of superficial injection techniques, including trigger point injections, LA injections, dry needling, and acupuncture are commonly used in MPS . HoweverClinicalTrials.org PRS under registration no. NCT04751110. STROBE checklist was used to help design and conduct the study.Local ethics committee approval  was obtained for this prospective, observational study. Our study was designed and conducted in accordance with the ethical principles specified in the Helsinki Declaration. All participants were informed about the study, and written informed consent was obtained from all patients. This study was registered at The inclusion criteria for the study were as follows: (1) be aged between 18 and 60 years; (2) experienced pain for at least 12 weeks in the thoracic paravertebral region between T2-T9; (3) presence of at least one active myofascial trigger point (MTrPs); and (4) pain with a numerical rating scales (NRS) score ≥3 lasts for at least three months. The active MTrP diagnosis was based on the fulfillment of all the following criteria: (1) palpable taut band; (2) presence of a hypersensitive tender spot within the taut band; (3) patient recognition of familiar referred pain symptoms upon compression of the nodule; and (4) painful limitation of full stretch range of motion (12).The exclusion criteria for the study were as follows: (1) cervical radiculopathy, fibromyalgia, shoulder joint disease, chronic fatigue syndrome, rheumatic diseases, history of surgery or traumatic event, and malignancy as a cause of pain (2) use of anticoagulants; (3) history of bupivacaine or dexamethasone allergy; (4) history of injection for MPS within the last six months; (5) decline to participate; and (6) pregnancy.While the patient was positioned prone and the ipsilateral arm adducted across the chest, under aseptic conditions, a linear high-frequency ultrasound transducer was placed 2–3 cm medial of the medial border of the scapula on the sagittal plane at the T5–T6 level. Cutaneous and subcutaneous layers, the trapezius muscle, rhomboid major muscle, intercostal muscle, ribs, and pleura were visualized . We inseDescriptive data collected at baseline included age, gender, and body mass index (BMI). Patients were assessed at baseline, just after the intervention, at day 1, and 1, 2, 4, and 6 weeks after the intervention.The NRS is a widely used scale to assess the severity of pain felt by a patient. The patient rates pain on a scale of 0 to 10, with 0 representing ‘no pain’ and 10 representing ‘worst pain’ imaginable. The NRS has been shown to have a strong correlation with descriptive scales, as well as high sensitivity and reliability . TherefoThe secondary outcome measures were quality of life, neck function, and patient satisfaction degree after treatment. The quality of life (QoL) was assessed via SF-36, which consists of 36 items encompassed in 8 dimensions: physical function, physical role, bodily pain, general health, vitality, social function, emotional role, and mental health and 2 summary values for Physical Component Summary (PCS) and Mental Component Summary (MCS) . SubscalDisability was measured by using the Neck Disability Index (NDI). The Turkish version of this scale was found valid and reliable. The questionnaire consists of 10 items in which each section is scored on a 0–5 rating scale, and the total score ranges from 0 to 50. Higher scores indicate greater disease severity . NDI meaSample size calculations were performed using G*Power software version 3.1.9.7  according to our preliminary study data. In this study, we found the mean NRS score 2.5± 0.8 at 6 weeks. Using the results of this previous study and considering the NRS as a primary outcome, a sample size of 30 patients was determined to be necessary in order to detect a %20 difference, an α level of .05, and power of 80%.Data were analyzed using the SPSS version 23.0 statistics program . Continuous quantitative data with normal distribution were presented as numbers, mean ± standard deviation, with abnormal distribution were presented as median (interquartile range). The compatibility of the variables to normal distribution was checked with a Kolmogorov–Smirnov test. The paired sample test was applied to parametric data for the statistical evaluation of repeated measurements. For abnormally distributed variables, intragroup distribution was compared using Friedman’s test. If present, within group comparisons of the differences were evaluated using the Bonferroni adjusted Wilcoxon signed ranks for post hoc analysis. P < 0.05 was considered statistically significant.χ2 = 105.94, p < 0.001) using a Friedman test. When binary time points were compared to find source of difference in NRS scores, there was a statistically significant difference immediately after treatment, at day 1 and week 1,2,4, and 6 compared to the pretreatment NRS (p < 0.001) . In total 53.3% of patients were very satisfied with pain management, 36.6% were satisfied, and 3.3% were not satisfied (All 30 patients diagnosed with MPS completed the study. The demographic characteristics of patients are summarized in < 0.001) . There watisfied . ChangesIn this study, we evaluated the clinical effect of US-guided RIB in patients with MPS. Our results showed that the severity of pain was significantly reduced after the block procedure for a 6-week follow-up period. Also, our study demonstrates that RIB improves the quality of life, disability, and patient satisfaction in the majority of the patients.The ultrasound revolution has shown its effect on the practice of regional anesthesia and pain medicine. Nowadays, there is increasing interest and, therefore, new research studies in US-guided IFB. RIB is a recently demonstrated IFB as an alternative technique to the paravertebral and thoracic epidural block. The literature on RIB provides evidence that this technique can lead to effective and long-lasting perioperative analgesia in breast and thoracic surgeries ,18. SimiFascia opens the possible keys for understanding the etiopathogenesis of pain syndromes such as chronic low back pain, myofascial pain syndrome, and fibromyalgia ,28. SeveFascia has a dynamic structure regarding its mechanical and physiological properties. The autonomous contractile elements it has and the movement of the musculotendinous structures attached to it explain the dynamic properties of the fascia. . PerformIn MPS, sensitization of polymodal type receptors (PMR) plays an important role in the development of the MTrPs. Superficial approaches such as dry needling, trigger point injections, and acupuncture provide analgesia by activating cutaneous PMR . StimulaSome limitations of this study should be considered. First, it had a short follow-up period; the effects were evaluated in only 6 weeks. Second, although our study could be criticized for the lack of a sham group, we considered that it is unethical to apply RIB in a placebo group with saline or intentionally puncture the fascia of muscles. However, this study could provide data for a sample size calculation for future randomized controlled trials. Third, NRS, Visual Analogue Scale, McGill pain questionnaire, and Pain Rating Scale are widely used scales for assessing pain intensity, however, we only used the NRS score as a primary outcome measure.In conclusion, this observational clinical study demonstrated that the US-guided RIB could be an alternative treatment modality in patients suffering from myofascial pain. Furthermore, our study showed that RIB had improved neck function, physical and mental quality of life, and patient satisfaction among patients with MPS. We suggest that RIB may gain an essential place in the treatment algorithm of MPS. However, further clinical studies are required to compare its effectiveness and safety to conventional techniques performed in MPS.


The predominant diagnostic pattern identification employed was “depressed liver qi transforming into fire” (19.8%). Herbal medicine (HM) was the most common treatment (44.2%). The most frequently used HM prescriptions were Ondam-tang (16.9%), Eokgan-san (15.7%), and Sihogayonggolmoryeo-tang (14.4%). KMDs recognized HM as the most effective among the KM treatments (54.3%). The results of this study elucidate the current clinical practice patterns of KM for ADHD. Based on these findings, a treatment protocol can be developed to provide optimized KM treatment services to patients with ADHD.To alleviate the symptoms of attention deficit/hyperactivity disorder (ADHD) in children and reduce the side effects of psychostimulants, parents are opting for complementary and alternative medicine as a therapeutic option. Korean medicine (KM) has been used by Korean medicine doctors (KMDs) to treat ADHD with herbal medication and acupuncture. This study aimed to conduct a cross-sectional survey on the clinical practice patterns of KM for ADHD in children targeting KMDs. The questionnaire included aspects related to patient characteristics, diagnosis, treatment modalities, and perceptions regarding KM. Questionnaires were distributed to all KMDs via e-mail, and the online surveys were conducted from 1 to 15 February 2023. A total 2.1% of KMDs ( Attention deficit/hyperactivity disorder (ADHD) is one of the most prevalent neurodevelopmental disorders in childhood and is characterized by age-inappropriate inattention, hyperactivity, and impulsivity ,2. ADHD According to the Health Insurance Review and Assessment Service Big Data Open portal , the totIn the management of pediatric patients with ADHD, pharmacotherapy and behavioral therapy are commonly employed either separately or in combination . MethylpThe Republic of Korea’s dual medical system provides both conventional Western medicine (WM) and Korean medicine (KM) modalities ,15. KM, Various complementary and alternative medicines (CAMs) have been used to improve ADHD symptoms and reduce the risk of ADHD by minimizing the use of psychostimulants with interventions, such as behavioral therapy, parental counseling, herbal medicine, and acupuncture ,19. EastThis study was aimed at conducting an online survey of the clinical practice patterns of KM, including the clinical characteristics of patients, diagnostic tools, PI, treatment methods, and perceptions of KM treatment for ADHD in children and adolescents, which are currently being performed by KMDs. Although this study has a limitation in its reliance on self-reported data from KMDs, the anticipation is that the results of this study will serve as preliminary data for systematic reviews or the development of treatment protocol in the future.This was a cross-sectional web-based survey targeting KMDs conducted to understand the current status of KM treatment for ADHD.(1)Sociodemographic data of respondents: Sex, age, years of clinical experience, place of work, and type of specialty credentials;(2)Clinical characteristics of ADHD patients: Monthly number of first-time patients, treatment period, cost per treatment, main age group of ADHD patients treated, concurrent Western treatment, and referrals to Western medical institutions;(3)Diagnosis of ADHD: Diagnostic tools used in diagnosis, pattern identification (PI);(4)Treatment of ADHD: Main treatment methods, name of herbal medicine, frequently used single herbs and acupoints, duration of herbal medicine and acupuncture, types of herbal medicine formulation, acupuncture, pharmacopuncture, and manual or exercise therapy;(5)Perceptions of KM treatment for ADHD: Effects of KM treatment for children with ADHD, effective KM treatment methods, advantages and disadvantages of KM treatment, and items that require additional training for KMDs;(6)Evaluation of the safety and effectiveness of KM treatment: Periods and indicators.A questionnaire was developed to investigate the current clinical patterns of KM treatment for ADHD. The initial draft of the questionnaire was constructed by a researcher who is a licensed KMD, a KM pediatrician with more than 15 years of clinical experience, and a professor of pediatrics at KM University. The initial draft was based on a questionnaire from existing survey articles on KM treatment ,30,31. BDomains (3) and (4) intended to use information on the diagnosis and treatment used by the KMD as reference data for future research of actual patients or systematic reviews. The data obtained through domains (5) and (6) were used for the development and application of treatment protocols for ADHD and training medical personnel.Questions about PI, name of the herbal medicine prescription, single herbs, and acupoints were developed with reference to KM pediatric textbooks . To ensuhttps://www.moaform.com/, accessed on 20 February 2023). The survey site was set up to allow only one input per Internet Protocol (IP) address assigned to the participant, preventing multiple responses from one computer. For the survey created on this platform, the response data can be downloaded as an Excel file without including information that can identify the respondent. The responses were collected between 1 February 2023 and 15 February 2023. In order to enhance the response rate, reminders were sent, and gift certificates were provided through a lottery.In the Republic of Korea, an individual who has completed a 6-year curriculum at a university of KM is eligible to take the KMD’s licensing exam, and licensed KMDs who have passed the exam can choose a specialist course consisting of a 1-year internship and a 3-year residency. Upon successful completion of this course and passing the qualification examination, the individual attains the status of a Korean Medicine specialist. This specialization encompasses eight distinct fields: internal medicine, acupuncture and moxibustion, pediatrics, gynecology, neuropsychiatry, otorhinolaryngology and dermatology, rehabilitation medicine, and Sasang constitutional medicine. As of 2020, among the 22,038 licensed KMDs, 3293 (14.9%) were KM specialists with licenses. Within this cohort of specialists, 198 (6%) were categorized as KM neuropsychiatrists and 121 (3.7%) were designated as KM pediatric specialists. These specialized fields are closely associated with the treatment of conditions like ADHD . The reqhttps://www.moaform.com/, accessed on 20 February 2023). The survey site was set up to allow only one input per Internet Protocol (IP) address assigned to the participant, preventing multiple responses from one computer. For the survey created on this platform, the response data can be downloaded as an Excel file without including information that can identify the respondent. The responses were collected between 1 February 2023 and 15 February 2023. In order to enhance the response rate, reminders were sent, and gift certificates were provided through a lottery.In the Republic of Korea, an individual who has completed a 6-year curriculum at a university of KM is eligible to take the KMD’s licensing exam, and licensed KMDs who have passed the exam can choose a specialist course consisting of a 1-year internship and a 3-year residency. Upon successful completion of this course and passing the qualification examination, the individual attains the status of a Korean Medicine specialist. This specialization encompasses eight distinct fields: internal medicine, acupuncture and moxibustion, pediatrics, gynecology, neuropsychiatry, otorhinolaryngology and dermatology, rehabilitation medicine, and Sasang constitutional medicine. As of 2020, among the 22,038 licensed KMDs, 3293 (14.9%) were KM specialists with licenses. Within this cohort of specialists, 198 (6%) were categorized as KM neuropsychiatrists and 121 (3.7%) were designated as KM pediatric specialists. These specialized fields are closely associated with the treatment of conditions like ADHD . The reqThis study was approved by the Institutional Review Board of Daegu Haany University (IRB No. 2022-4-01). All participants were informed of the purpose and details of the study, and anonymity was guaranteed through an e-mail cover letter prior to participation. Participants were asked to respond to the questionnaire only if they voluntarily agreed to participate and were informed that they could withdraw at any time, even after they had started responding.p-value < 0.05 was set to determine statistical significance. Data were analyzed using Microsoft Excel 2016  and SPSS .Descriptive statistics were used, and categorical data were presented as frequencies and percentages. Continuous variables are expressed as mean ± standard deviation. Multiple-response analysis was used for questions that allowed multiple responses. For categorical data of clinical experience of the KMDs, linear-by-linear association was used, and for categorical data of the level of medical institution, chi-square or Fisher’s exact test were used. A A total of 25,574 KMDs registered with the Korean Medical Association received an e-mail, and 537 (2.1%) of them checked the e-mail and completed the survey. All of them satisfied the requirements of the participants, and 537 KMDs were included in the final analysis. The respondents’ demographic characteristics are presented in n = 475, 88.5%) reported that the monthly average number of first-time ADHD patients was less than five in the past year. As for the average treatment period, one–three months accounted for 29.6%, followed by less than one month with 27.2%, and three–six months with 25.7%. The main age group of ADHD patients under treatment was children in early elementary school (7–9 years), which accounted for the largest proportion at 47.2%, followed by children in the upper grades of elementary school (10–12 years) at 26%. A total of 24.2% of the KMDs responded that the rate of combining Western treatment for ADHD was 25–50%, followed by 50–75% (23.5%), and 75–100% (22.3%). When ADHD patients received WM treatment, the most common type of treatment was medications (43.7%); 442 respondents (82.3%) stated that the number of direct referrals to WM institutions in the past year was zero, and the main purpose of referral was for diagnosis and examination of ADHD (48.4%), followed by WM prescriptions at 35.8%.The current status of the respondents’ treatment of ADHD in children and adolescents is presented in Of the responding KMDs, 74.1% answered that they use PI when diagnosing ADHD, and the most commonly used PI method was “PI of Qi, Blood, Fluid, Humor, and Organ system diagnosis” based on the KM textbooks (62.8%) . The titAs shown in The most commonly used acupuncture was “Meridian points acupuncture” (49.5%). As for acupoints, PC6 (14.9%), GV20 (14.4%), and LI4 (14.3%) were found to be used frequently. The recommended duration of acupuncture was also more than three months and less than six months (36.2%).The most commonly used pharmacopuncture treatment was Cervi Pantotrichum Cornu (44.9%), followed by Hominis Placenta (26.5%). The most frequently used manual and exercise therapy was Chuna manual therapy (50.9%), followed by acupressure (28.3%).p = 0.037) (p = 0.262). However, the use of herbal medicine or acupuncture treatment did not differ significantly according to the level of the affiliated medical institution when the chi-square or Fisher’s exact test was used (both p > 0.05).When the usage pattern of the main KM treatment modalities was analyzed by linear-by-linear association according to clinical experience, the longer the clinical experience, the higher the usage rate of herbal medicines (= 0.037) . AcupuncBased on the treatment experience, the average score was 3.49 ± 0.76 on a five-point Likert scale when asked about the overall effect of KM treatment on children and adolescents with ADHD  . Most ofRegarding the items on the evaluation period for the effectiveness of ADHD treatment in children and adolescents, 46.6% answered three months, and 36.5% answered one month . As for The present study was a web-based, cross-sectional survey targeting KMDs on the use of KM treatment for ADHD in children and adolescents. The questionnaire items included information about the patients’ clinical characteristics, diagnosis, treatment, and perceptions. A total of 537 KMDs completed the survey, and 411 (76.5%) of them were KMDs working at KM clinics, which are primary medical institutions. As of 2020, 16,138 (73.2%) of the total number of 22,038 KMDs in Republic of Korea are working at KM clinics ,34; it sOf the respondents, 24.2% indicated that 25% to 50% of children with ADHD under treatment received concurrent Western treatment; 23.5% answered “50–75%”, and 22.3% answered “75–100%”. As for the type of concurrent treatment, WM prescriptions were the most common (43.7%). On the other hand, most KMDs (82.3%) responded that there was no case of direct requests to Western medical institutions last year. Therefore, it is possible that the patient and guardian chose both medical institutions out of necessity rather than when a KM institution requested a Western medical institution for consultation. Medical care in Korea is a dual medical system in which patients can choose to receive health insurance treatments in WM and KM. According to the 2022 Korean medicine use survey, parents responded that the most important purpose for their children under the age of 19 to use KM was “disease treatment” (43%), followed by “health promotion” (40.5%) and “growth clinic” (27.6%) . For patIn a meta-analysis of 746 children with ADHD , combineIn East Asian herbal medicines that included traditional Chinese and Korean medicines, based on the concept of PI, different prescriptions can be administered according to the type of symptoms, even with the same diagnosis. Among the PI methods, the KM textbook-based “Qi, Blood, Fluid, Humor, and Organ system pattern identification” was most frequently used. Among them, the frequently used titles of PI were “depressed liver qi transforming into fire” (19.8%), “phlegm-fire harassing the heart” (15.5%), “dual deficiency of the heart-spleen” (15.4%), “effulgent heart-liver fire” (15%), and “kidney deficiency and liver hyperactivity” (13.6%). In a study on the development of a PI questionnaire for ADHD in KM , the fouThe respondents answered that herbal medicine treatment was used most frequently in KM, and among the names of the herbal medicine prescriptions, Ondam-tang, Eokgan-san, and Sihogayonggolmororyeo-tang were used to treat ADHD in children and adolescents. Ondam-tang  has been reported to be effective in treating mental disorders ,40, inclThe five most frequently prescribed herbs were Polygalae Radix, Acori Graminei Rhizoma, Poria, Zizyphi Spinosae Semen, and Rehmanniae Radix Preparat. Among the above drugs, four, except for Zizyphi Spinosae Semen, were included in the top 12 frequently used herbs in a literature review  that anaIn addition, the items to be supplemented were answered in the following order: treatment cost (26.7%), treatment information (promotion and awareness) (23.9%), and convenience of treatment  (19%). In the section on Korean medicine treatment status, 32.6% answered 10,000–20,000 KRW as the average cost of treatment (copay) per treatment based on the previous year, followed by a response of 20,000–50,000 KRW at 25%. According to the respondents, the average treatment period was ‘1–3 months’ (29.6%), ‘less than 1 month’ (27.2%), and ‘3–6 months’ (25.7%). Among herbal medicines for treating ADHD, the compound herbal decoction emerged as the most frequently used form. Compound herbal decoctions have the advantage of tailoring the prescription to each individual patient, thereby potentially enhancing treatment effectiveness. However, a problem arises from the fact that these decoctions are not covered by health insurance, leading to potential increases in the financial burden faced by patients and their caregivers. Considering that ADHD requires long-term treatment and follow-up, it is necessary to investigate the economic feasibility of KM treatment. Considering that ADHD requires long-term treatment and follow-up, the economic feasibility of KM treatment should be investigated, and the health insurance coverage should be expanded for herbal medicine treatment. Moreover, additional research is needed on the optimal treatment period or frequency of herbal medicines and acupuncture.Of the respondents, 48.6% said that the evaluation of ADHD treatment effect was based on clinical symptoms without specific indicators, followed by 14% of those who said that ADHD-RS-IV was used. Of the respondents, 46.6% answered that the treatment effect evaluation was performed every three months. In addition, the majority of respondents said that safety was evaluated with ‘Changes in the child’s general condition’ (38.7%), and the most frequent evaluation cycle was once a month (42.5%). Considering that most KMDs work in primary care institutions, cooperation with other medical personnel should be fostered to ensure a clear evaluation of safety and effectiveness. A standardized evaluation protocol that can be used in primary care institutions should be developed, and medical staff should be systematically trained. To this end, opinion gathering and consensus processes, such as interviews and Delphi surveys with experts in KM treatment for children and adolescents with ADHD, should be conducted.This study had several limitations. First, only a small number of KMDs responded to the questionnaire. There may have been invalid e-mail addresses in the emails of the Association of Korean Medicine, and this result may not reflect the opinions of all KMDs. In future surveys, it can be considered to use a combination of methods such as sending a questionnaire link through a mobile phone registered with the Association of Korean Medicine or conducting a paper survey at a national refresher education conference for KMDs. In addition, it is important to acknowledge that the outcome of this study serves only as a reference for investigating the clinical practice patterns of KM treatment. Based on this, additional information should be collected through in-depth interviews with KMDs who predominantly engage in ADHD treatment or by conducting research using treatment data from medical institutions. Second, this study used a self-reported survey, and a response bias may have occurred. There may have been recall bias, insincere answers, and exaggeration of treatment advantages. Third, the reliability and validity of the questionnaire used in the study were not assessed. While existing questionnaires that investigated the treatment patterns of KMDs were referred to in the design of the questionnaire, none of these questionnaires had been subject to formal reliability or validity testing ,30,31. TNevertheless, this study was the first to investigate the actual practice of KM treatment for ADHD in children and adolescents by targeting KMDs. Based on the results of this survey, KMDs can be used as references for the diagnosis and treatment of pediatric patients with ADHD. In the future, to accumulate more rigorous evidence, SRs on the effectiveness and safety of each KM treatment and data accumulation research using actual patient data should be conducted. Furthermore, a treatment and evaluation protocol that reflects the clinical practice pattern of current KM treatment will be developed, and medical personnel training will be implemented to enable a more reliable, systematic, and standardized ADHD treatment.This study was the first to show the current clinical practice status of KMDs, including the diagnosis, evaluation, treatment, and awareness of ADHD in children and adolescents. Based on this cross-sectional study, it is necessary to accumulate evidence for the treatment of ADHD in children with KM through various types of research, such as SRs on each KM intervention method, studies using patient-care data in an actual medical setting, and randomized control studies. Based on this, a protocol for effective, safe, and optimized KM treatment should be established and implemented by KM medical staff through professional and systematic training.


Additionally, since wearables have limited resources, analysing the parameter requirements of attention modules can serve as an indicator for optimizing resource consumption. In this study, we explored the performance of CBAM on the DeepConvLSTM architecture both in terms of recognition performance and the number of additional parameters required by attention modules. In this direction, the effect of channel and spatial attention, individually and in combination, were examined. To evaluate the model performance, the Pamap2 dataset containing 12 daily activities and the Opportunity dataset with its 18 micro activities were utilized. The results showed that the performance for Opportunity increased from 0.74 to 0.77 in the macro f1-score owing to spatial attention, while for Pamap2, the performance increased from 0.95 to 0.96 owing to the channel attention applied to DeepConvLSTM with a negligible number of additional parameters. Moreover, when the activity-based results were analysed, it was observed that the attention mechanism increased the performance of the activities with the worst performance in the baseline model without attention. We present a comparison with related studies that use the same datasets and show that we could achieve higher scores on both datasets by combining CBAM and DeepConvLSTM.Sensor-based human activity recognition with wearable devices has captured the attention of researchers in the last decade. The possibility of collecting large sets of data from various sensors in different body parts, automatic feature extraction, and aiming to recognize more complex activities have led to a rapid increase in the use of deep learning models in the field. More recently, using attention-based models for dynamically fine-tuning the model features and, in turn, improving the model performance has been investigated. However, the impact of using channel, spatial, or combined attention methods of the  Mobile and wearable device diversity and usage rates are expanding due to technical advancements. These devices have several integrated sensors, particularly motion sensors, that can be used to track the user’s movements. Sensor-based human activity recognition (HAR) ,2,3 is aOne challenge involves the positions where the device is carried/worn on the body. Sensor readings coming from different body parts with the changing activities differ. Several studies have only used a single body-location sensor(s) for HAR ,5,6. HowSensor data collected from different body parts is time-series data; hence, HAR is modelled as a multivariate time-series classification problem. Often, sensor signals are segmented into windows to capture the temporal information in the sequence of activities. Deciding on the optimal window size is one of the challenges since it impacts recognition performance. Many different classification algorithms have been applied in the HAR domain; in particular, shallow models have been extensively studied . They acParticularly, sequential deep learning models, such as LSTM, can help in modelling the temporal information in time-series signals and overcome the challenge of deciding on window size. However, as mentioned in , an evenAttention mechanism  is an emThere are a few recent studies that have investigated the incorporation of some attention mechanisms in deep models for HAR ,27,28,29Although the effect of using attention with some deep learning architectures has been investigated in related studies, we are interested in exploring how an already good-performing deep model, DeepConvLSTM, can benefit from channel, spatial, or both attention methods.We performed an extensive set of experiments to explore how different reduction ratios and kernel sizes of attention and the application of attention at different depths of the deep architecture impact the performance of recognition on two different datasets where multiple body positions were involved with a large set of activities. In We also found that adding attention did not significantly increase the number of additional model parameters. Although we did not run these models on a mobile or wearable device in this work, having less complex models is important for future work when these models are ported to mobile or edge devices where computational resources are limited compared to a server or a cloud environment .In order to evaluate the performance of using CBAM in HAR, we used two datasets: Pamap2  and OppoThe remainder of the paper is organised as follows: We present the related studies focusing on attention on sensor-based HAR in Humans divide their attention by highlighting interesting information and suppressing irrelevant and potentially confusing ones while performing complex tasks. Model attention in deep neural networks inspired by humans’ perceptions is proposed in . As mentTo the best of our knowledge, few recent attempts have focused on using an attention mechanism in the sensor-based HAR domain. Recently, in , authorsIn , the autThe authors of  were theIn another study , the autThe most recent study , exploitAlthough innovations and advantages brought by deep learning algorithms are desirable for use in the field of HAR to increase recognition performance, resource consumption is a challenging issue in mobile and wearable devices. These devices are especially limited in terms of battery and memory, and even running the algorithms on these devices in the inference mode is a problem that requires attention. The number of additional parameters brought by applying attention is generally less, as in the case of the bottleneck attention module  and CBAMThe authors of  introducIn , the autResearchers have begun to use CNN-based architectures frequently in the sensor-based HAR domain because of the considerable resource consumption of time-series models  and the quick/efficient development of new CNN-based approaches. Subsequently, new models have emerged, starting with convolutional layers, which have an effective feature extraction capability and can thus incorporate temporal dependencies with subsequent LSTM layers as in the case of DeepConvLSTM architecture. To the best of our knowledge, only one study has employed attention on DeepConvLSTM  with a fIn this section, we explain the building blocks of our methodology. First, we summarize the CBAM module and then the details of the DeepConvLSTM model. The integration details of these blocks are presented in CHatt) module and spatial attention (SPatt) module. As the names suggest, the modules are designed to be applied after convolutional layers.In , authorsCHatt module uses maximum pooling (sharper effect) and average pooling (smoothing effect) in spatial dimension to the input feature, a multilayer perceptron (MLP) mapped by reduction ratio (r), and then a sigmoid activation is applied. The reduction ratio is the key parameter that controls the degree of dimensionality reduction to create a trade-off between computational efficiency and attention accuracy through a shared MLP module in the channel attention mechanism. A smaller reduction ratio can increase the expressive capacity of the channel attention mechanism but with the cost of higher computational complexity and vice versa for a larger reduction ratio. Depending on the specific application, the reduction ratio should be carefully tuned to achieve the best balance between attention performance and computational efficiency. More precisely, to compute channel attention map X∈X: C neurons in the input layer, C neurons in the output layer. After two output vectors are obtained from MLP, these vectors are merged using element-wise summation. Then, a sigmoid ). As suggested in the main paper, the attention modules are applied either after one of the convolutional layers or after every convolutional layer. In this study, we conducted experiments regarding how to use this attention mechanism from the perspective of resource-constrained devices while using sensor data since they have negligible parameter numbers. In There are multiple options to use DeepConvLSTM, presented in , is one open/close door [As reported in , hybrid ose door .The origIn this study, we used the well-known DeepConvLSTM model, which is already capable of modelling temporal dependencies. Moreover, we added CBAM to the existing DeepConvLSTM model to enhance the model’s performance by focusing on important channels and spatial regions within the convolutional layers of the architecture. By using a method focusing on the temporal aspect of sensor-based HAR with improvements in convolutional layers from channel and spatial aspects, we aim to have more accurate and powerful models for sensor-based HAR.CHatt reflects the 64 channels of each convolutional layer, and each of them contains the features extracted using convolutions along the temporal axis (height dimension). CHatt module helps to rescale the importance of each channel in the input feature. For the SPatt, pooling along channels are used, and therefore we achieve one mask for each signal–temporal feature pair. More details about how averaging along different dimensions reflect different properties in time series can be found in [CHatt is followed by SPatt (CHSPatt), which is applied after each convolutional layer of the DeepConvLSTM architecture. However, in our experiments, we applied CHatt, SPatt, or CHSPatt after the first, second, third, fourth, or all convolutional layers. The architecture presented shows us the maximum possible attention applied to the DeepConvLSTM architecture in this study.The overall architecture, including DeepConvLSTM with CBAM used in this study, is presented in found in . AdditioIn this section, we present the two datasets used in this study, which are extensively used in the sensor-based HAR domain , mainly Physical Activity Monitoring Dataset (Pamap2)  is a benchmark dataset used in multimodal human activity monitoring. The activity data of participants are captured by three inertial measurement units (IMUs) worn on the dominant wrist, chest, and ankle with a sampling rate of 100 Hz, a heart rate sensor with a sampling rate of 9 Hz, and a thermometer. Nine participants were involved in the data collection phase. The dataset contains 18 different daily activities. In this study, we investigated 12 activities that were performed by all participants , defined as the arithmetic mean of classes’ f1-scores, to reflect the more accurate model performances of models employing imbalanced datasets. Note that for Pamap2, 50 Hz was used as the sampling rate and 30 Hz for Opportunity. Descriptions of abbreviations used in this section for different attention settings are presented in While we aimed to improve recognition performance with the attention mechanisms, it was also crucial to avoid increasing resource consumption of the models since they are expected to be deployed on resource-constrained edge devices such as mobiles and wearables for HAR. The number of parameters in the model directly impacts the computational resources, such as CPU cycles, needed during both the training and testing phases. CPU cycles will also impact the battery consumption of the target devices. In other words, resource consumption and computation time will increase as the number of parameters in the model increases. Therefore, as we examine each attention mechanism in this direction, it is important to consider the number of additional parameters it brings to the model.Before examining the recognition performance of the models, we first present the number of parameters in each model in r: 1, 2, 4, 8, and 16) at different depths . As mentioned, abbreviations used for reduction ratios r and the number of layers after which attention was applied x, are given in In this section, we discuss the impact of channel attention with the use of various reduction ratios , while the performance of Close drawer 1 increases by 0.05 (0.52 to 0.57), while Open drawer 1 decreases by 0.05 (from 0.59 to 0.54). Considering the remaining gestures, we can observe that the performance of seven of them improve over 0.01, and three of them decrease by over 0.01. Moreover, for the Pamap2 dataset, Descending stairs, which initially has the lowest performance without attention, reaches a performance increase with the use of the channel attention module (from 0.89 to 0.92). Similarly, the activity Vacuum cleaning, which has the second lowest performance, achieved the highest performance increase (from 0.91 to 0.94) with the use of attention. Overall, for the Pamap2 dataset, we can say that channel attention brings a slight improvement in the average recognition performance. However, for the mostly confused activities, using attention increases the performance by 0.02.In w_CHatt(4)), which obtained equal performance with wo_attention. The highest increase of 0.02 (from 0.72 to 0.74) can be observed for w_CHatt2(8). Moreover, w_CHat3(1) achieved the lowest sstd of 0.005, which was 0.015 with wo_attention. As for the Pamap2 dataset, there was no critical increase in f1-score; however, by using channel attention models, we obtained more robust models, as with w_CHatt2(4) (sstd of 0.001), which was higher using wo_attention (sstd of 0.006).We also investigated channel attention’s impact using a five-fold cross validation technique. We separately reported each experiment’s average macro f1-score (denoted as f1-score) and sample standard deviation (sstd) of folds. In r: 3, 5, and 7) at different depths.In this section, we discuss how spatial attention impacts recognition performance in relation to the use of various parameters  and Open drawer 1 (from 0.59 to 0.72), which are the two activities with the worst performance when attention is not used. Although the recognition performance of most gestures is positively affected by the attention mechanism, Clean table gesture is an exception in this analysis and is negatively affected (with a decrease of 0.02) from the application of attention. Considering the activity-based results presented in Ascending stairs, Descending stairs, and Vacuum cleaning with a performance increase of 0.01, 0.04, and 0.01, respectively. Overall, spatial attention improves performance by, on average, 0.02 for Pamap2’s three worst-performing activities (lower than 0.92 in the w_SPatt1(3) (from 0.72 to 0.73) for Opportunity. Moreover, adding spatial attention could help obtain similar f1-score performances with more robust models. For example, instead of selecting the wo_attention model, which has an f1-score of 0.72 and an sstd of 0.015, we can choose w_SPatt3(5), which has an f1-score of 0.72 and an sstd of 0.006. Therefore, this model is more robust and can provide more reliable results.The results of spatial attention experiments using five-fold cross validation are presented in terms of f1-score and sstd in In this section, we discuss the impact of applying channel attention first and then spatial attention together. In this analysis, we used combinations of different channel and spatial attention parameters at different depths.The performance results for the Opportunity and Pamap2 datasets are presented in wo_attention are presented in wo_attention, we can observe that the greatest improvement in recognition performance was obtained with w_CHSPatt1(16)(3) (from an f1-score of 0.72 to 0.74 and from 0.015 sstd to 0.014 sstd). However, to have a more robust model, one may also choose an attention module with less or no improvement but more robustness. For Opportunity, this model could be w_CHSPatt1(1)(5) with an f1-score of 0.73 and 0.004 sstd, while for Pamap2, this could be an f1-score of w_CHSPatt2(1)(3) (0.95 and 0.001 sstd).For the impact of adding both attention mechanisms, the results obtained for the best- and worst-performing experiments compared to the performance of wo_attention model with the best-performing models of channel, spatial, and channel–spatial attention modules for both datasets. wo_attention and several attention modules for Opportunity and Pamap2, respectively.We investigated the impact of attention on each activity/gesture in the dataset by comparing the Close drawer 2 samples are falsely predicted as Open drawer 2, and 0.15 of Close drawer 3 samples are falsely predicted as Open drawer 3). The Clean table, Drink from a cup, and Toggle switch gestures perform better than do the rest. More particularly, their confusion apart from the Null class remains under 0.02. The gestures with the worst performance in the wo_attention model, where only 0.47, 0.52, and 0.56 of the samples are correctly predicted, are Close drawer 1, Close drawer 2, and Close fridge, respectively. Owing to the attention modules, a significant 0.12 and 0.08 improvement is achieved for the Close drawer 1 and Close fridge gestures, respectively, while this improvement is only 0.01 for Close drawer 2. Moreover, when the confusion matrices of Pamap2 datasets were investigated  and Pamap2 datasets (p < 0.001 from Wilcoxon t-test).In wo_attention), we conducted one-sample t-tests for each of the Opportunity and Pamap2 datasets. There are two input samples used, one for each dataset. For both datasets, input samples provided to the statistical tests include one performance result obtained with the baseline model (wo_attention) and 115 performance results obtained with attention-applied models . Statistical test results show that attention-applied models achieve significant results when compared against the baseline without attention model for Opportunity (p < 0.001 from Student t-test) and Pamap2 datasets (p < 0.001 from Wilcoxon t-test).Finally, to determine if baseline models with attention-applied models are statistically significant when compared against baseline without attention models  and in combination to understand the impact better. By adding channel and spatial attention modules to the DeepConvLSTM model, which is already good for modelling temporal dependencies in time series, we also better captured both channel-wise and spatial patterns in convolutional layers since the CBAM method is easy to apply in any convolutional layer with a negligible number of additional parameters.sitting and standing, while Opportunity contains more confusing microactivities/gestures such as open drawer or close door. DeepConvLSTM with CBAM outperformed regular DeepConvLSTM with use of channel attention (CHatt4(2)) for Pamap2 (from 0.95 to 0.96) and with use of spatial attention (SPatt3(5)) for Opportunity (from 0.74 to 0.77). Moreover, the number of parameters in the model created for Opportunity increased by about 0.006% with the addition of spatial attention, while the parameter number of Pamap2 increased by about 0.296% with the addition of Channel attention, which indicates this attention method is suitable for resource-constrained environments. Even though DeepConvLSTM is particularly good at discriminating closely related activities (such as ascending/descending stairs), we observed that by applying CBAM attention, we particularly improved the performance of the lowest-performing activities. Therefore, we understand that the CBAM improved the feature extraction capability of convolutional layers in DeepConvLSTM. Note that since the CBAM is designed to apply convolutional layers, we could also experiment on a CNN network; however, since hybrid models (CNN+LSTM) perform better than does CNN alone and because DeepConvLSTM models also include the temporal aspect of sensor data, we did not experiment with CNN alone.The proposed model was evaluated on two public sensor-based HAR datasets: Pamap2 and Opportunity. Pamap2 contains daily life activities such as Finally, we also compared our proposed system with recent deep learning architectures that employ attention mechanisms in the sensor-based HAR domain on the same datasets. The performance results with the number of parameters (when available) are presented in CHatt4(2) (from 0.95 to 0.96) for Pamap2 and using SPatt3(5) (from 0.74 to 0.77) for Opportunity. Since the activities in the Pamap2 dataset are not as challenging as those in Opportunity, the initial DeepConvLSTM performance was lower in Opportunity. Thus, the effect of attention was more evident.In this study, we investigated sensor-based human activity recognition with channel and spatial attention modules of the convolutional block attention module (CBAM). We followed a detailed analysis, with a focus on channel attention, spatial attention, and channel–spatial attention. We used a hybrid sensor-based HAR model, DeepConvLSTM, and applied attention at different depths to its convolutional layers. We evaluated the impact of models using two HAR datasets: Pamap2 and Opportunity. We observed that for each channel, spatial, and channel–spatial attention, applying attention outperformed the model’s initial (without attention) performance. Moreover, the highest increase was observed using


Background and Objectives: Total knee arthroplasty (TKA) involves blood loss, increasing the risk of postoperative anemia and delayed functional recovery. Intravenous (IV) iron supplementation limits postoperative anemia; however, the effectiveness of IV iron, administered one day before TKA, on postoperative anemia and functional recovery has scarcely been studied. Materials and Methods: We conducted a retrospective cohort study with propensity score matching using two consecutive groups of patients who underwent TKA using tranexamic acid: the iron group received 500 mg ferric derisomaltose intravenously one day before surgery (n = 46); the non-iron group did not (n = 46). Hemoglobin (Hb) level was determined at postoperative days (PODs) 2, 4, 6, 14, and 30. Ferritin, transferrin saturation (TSAT), and functional iron deficiency anemia (IDA) rate were measured at PODs 2, 4, 6, and 14. Length of hospital stay and transfusion rate were also evaluated. Results: The iron group had higher Hb levels at PODs 6, 14, and 30 and higher ferritin and TSAT at PODs 2, 4, 6, and 14. The functional IDA rate was significantly higher in the non-iron group at PODs 2, 4, 6, and 14. Length of hospital stay was significantly shorter in the iron group; however, the rate of transfusion did not differ between the two groups. Conclusions: IV iron administered one day before TKA was associated with postoperative anemia recovery and length of hospital stay; however, it did not lower the postoperative transfusion rate. Total knee arthroplasty (TKA) is associated with substantial blood loss and postoperative anemia, which may delay patient recovery, lengthen hospital stay, and eventually lead to poor clinical outcomes ,2,3. AddOral or intravenous (IV) iron supplementation is a key element of patient blood management, with IV iron found to have a faster recovery effect on Hb levels and fewer side effects ,7,8. It Several factors can affect recovery from postoperative anemia, such as the total amount of iron as well as circulating iron levels ,14. HoweWe aimed to analyze the effect of IV iron administration one day before TKA on postoperative anemia and functional recovery and determine whether IV iron administration can reduce the occurrence of functional IDA. We hypothesized that IV iron administration one day before surgery would facilitate postoperative anemia and functional status recovery and could reduce the occurrence of functional IDA after TKA.Following Institutional Review Board approval (IRB No. 2021-04-021), we performed a retrospective cohort study of 158 consecutive patients who: (1) underwent primary unilateral TKA for degenerative arthritis with Kellgren–Lawrence grade 3 or 4; and (2) either did or did not receive preoperative IV iron administration between April 2019 and November 2020. From February 2020, we administered preoperative IV iron to all patients undergoing TKA to improve Hb recovery. To avoid selection bias, consecutive patients received the same perioperative protocol with or without preoperative IV iron supplementation, depending on when the surgery was performed. The exclusion criteria were as follows: (1) presence of inflammatory arthritis, such as rheumatoid arthritis; (2) history of open knee surgery; (3) presence of other secondary arthritis conditions, such as infectious arthritis or traumatic destructive arthritis; and (4) incomplete medical records regarding iron panels and patient’s quality of life index. After the exclusion of 25 patients, a total of 87 patients were included in the non-iron group, and 46 patients were included in the iron group.®, Pharmacosmos A/S, Holbæk, Denmark) diluted with 200 mL of normal saline was administered intravenously over 2 h. Except for the IV iron administration, all patients underwent primary unilateral TKA according to the same surgical protocol. In both groups, a standard medial parapatellar approach was followed, with a tourniquet inflated to 300 mmHg. The surgical implant was a cemented posterior stabilized prosthesis in all patients. The tourniquet was deflated after the cement was completely set, and the prosthesis was firmly fixed. A suction drain was clamped and inserted before the capsule was closed, and a solution of 1 g tranexamic acid in 50 mL normal saline was injected into the articular space. The drain remained clamped for 2 h after the operation before being released.In the iron group, one day before surgery, 500 mg ferric derisomaltose (MonoferPatients in both groups had the drain removed at 48 h postoperatively. From postoperative day (POD) 2 to POD 30, patients were administered aspirin as an anticoagulant. Range-of-motion exercises were started on POD 1, and walker ambulation began on POD 2. Transfusion of allogeneic blood was only indicated when the Hb concentration decreased below 8 g/dL with abnormal symptoms, such as tachycardia and hypotension.We retrospectively collected preoperative data from medical records, including age, sex, body mass index (BMI), and American Society of Anesthesiologists Physical Status (ASA-PS) classification. The primary outcome variables were serial values of Hb and iron panels, including serum ferritin and TSAT, measured preoperatively and on PODs 2, 4, 6, 14, and 30. Using the values of iron panels and C-reactive protein (mg/L), rates of absolute and functional IDA were calculated preoperatively and on PODs 2, 4, 6, and 14. Absolute IDA was defined as low Hb  with TSAT < 20%, ferritin < 30 ng/mL, and no sign of inflammation; conversely, functional IDA was defined as low Hb  with TSAT < 20%, ferritin > 100 ng/mL, and CRP > 5 mg/dL .The secondary outcome variables were transfusion rate and length of hospital stay (LOS). LOS was calculated as the number of days in the hospital from the day of surgery to the day of discharge. The primary target for LOS after TKA was set at six days in our institute. After that point, discharge was determined by agreement between the operator and physiotherapist that the patient was medically stable and that their functional ability was sufficient to allow discharge to the patient’s home. This included being able to climb up and down several steps, walk on flat ground using a walker for >10 min, and bend their operated knee for >90°. After discharge, patients were scheduled for a follow-up on PODs 14 and 30.p < 0.05 was considered statistically significant. All statistical analyses were performed using SPSS version 24 (IBM Corp.).Before analysis, propensity score matching was performed using age, sex, BMI, and ASA-PS classification as variables. Propensity scores were generated using SPSS version 24 . Each patient in the iron group (n = 46) was assigned a matching patient in the non-iron group (n = 87), with a match tolerance (maximum difference between propensity scores) of 0.1. Therefore, 46 patients were ultimately included in each group . After mp = 0.032), 14 , and 30  than the non-iron group (p = 0.210). Additionally, absolute iron deficiency was not observed in either group after surgery. However, the rate of functional iron deficiency was significantly higher in the non-iron group than in the iron group on PODs 2 , 4 , 6 , and 14  (p = 0.411), 4 , 6 , and 14 . The rate of transfusion did not differ between the two groups . However, LOS was significantly shorter in the iron group than in the non-iron group . There were no postoperative complications in either group up to POD 30.Age, sex, BMI, and ASA-PS scores did not differ between the groups . The iroon group . Additioon group . The rat= 0.002) . The CRPThe primary findings of this study were as follows: (1) the iron group had faster Hb recovery at PODs 6, 14, and 30; (2) the iron group had a significantly lower rate of functional IDA during the study period; (3) the rate of transfusion was not different between the iron and non-iron groups; and (4) LOS was shorter in the iron group than in the non-iron group. To the best of our knowledge, this is the first clinical study to analyze postoperative anemia and functional recovery following IV iron administration one day before TKA.Conventionally, oral iron has been used to treat IDA . HoweverCurrently, three IV iron formulations  are most commonly used because they do not have severe side effects . Many stThe current protocol states that IV iron should be administered to IDA patients 4 weeks before surgery; although this is the ideal treatment, it is not always possible in the field of orthopedic surgery . Jeong eIn this study, serum ferritin and TSAT were higher and the rate of functional IDA was lower (during the study period) in the iron group than in the non-iron group, which resulted in faster Hb recovery of patients in the iron group. Serum ferritin levels reflect the total amount of iron stored in the body, and TSAT reflects the amount of circulating iron, which can be directly used in erythropoiesis ,34,35. SIn our study, despite faster Hb recovery and shorter LOS in the iron group, the transfusion rate was not different between the two groups. Regarding LOS, several studies have already shown that postoperative anemia was associated with postoperative functional recovery after major orthopedic surgery ,42,43. FOur study has some limitations. First, this study had a relatively short-term follow-up period. Additional studies with long-term follow-up are warranted to evaluate the changes in Hb, ferritin, and TSAT levels and to identify whether the differences in Hb and iron profile levels between the two groups can lead to differences in patient-reported outcomes in the long term. Second, due to the retrospective design of the study, there may be concern regarding possible selection bias. However, the treatment decision of whether to administer IV iron was based on the date of the surgery, not on other parameters. Furthermore, patients in both groups were treated using the same surgical procedure with identical perioperative management. Moreover, propensity score matching was also performed to appropriately set the usage of IV iron as the only independent variable. Thirdly, we assumed that rapid Hb recovery affects patients’ functional recovery and leads to a shorter hospital stay. It should be noted that various factors, other than Hb level, could potentially affect postoperative functional recovery or LOS. Given the retrospective design of the study, other confounding factors may not have been controlled, and could have influenced the results. Lastly, this study was performed using a relatively small sample size due to the limited number of eligible patients. Prospective studies with a sufficient power analysis are warranted to confirm our findings.IV iron administered one day prior to TKA was associated with postoperative anemia recovery and LOS, although it did not lower the postoperative transfusion rate. As approximately half of the patients undergoing TKA experience postoperative functional IDA, clinicians may consider the use of IV iron to improve iron availability. Furthermore, based on our study, further studies are warranted to investigate the definite relationship between IV iron administered one day prior to TKA and postoperative functional recovery.


The length of hospital stay of the patients who underwent postoperative transfusion in 2019 (n = 197) was 13.97 ± 11.95 days, which was not significantly different from that in 2020 (n = 167), i.e., 16.44 ± 17.90 days (p = 0.118). Further, 9 of 197 postoperative transfusion patients died in 2019, while 8 of 167 patients died in 2020 (p = 0.920). The COVID-19 pandemic resulted in limited blood supply and reduced postoperative transfusions; however, patient prognosis was not affected.The coronavirus disease (COVID-19) outbreak affected the utilization and management of blood products in hospitals. Blood shortages occurred owing to social distancing policies and reduction in blood donors. However, only a few studies examined whether these changes affected blood usage and transfusion patterns. We retrospectively reviewed blood component usage according to hospital departments and phases of surgery in transfused patients admitted between 1 March 2019 and 28 February 2021, in a single center in Anyang, Korea. We also analyzed the length of hospital stay and mortality to determine prognosis. In 2020, 32,050 blood components were transfused to 2877 patients, corresponding to 15.8% and 11.8% less than the rates in 2019, respectively. Postoperative usage of blood products significantly decreased in 2020 (3.87 ± 6.50) compared to 2019 (7.12 ± 21.71) ( The continuing coronavirus disease COVID-19) pandemic has become a major global concern. It was challenging to find an appropriate therapy at the beginning of the pandemic in the context of the COVID-19 impact on clinical pathways, and this caused a delay in providing appropriate treatment 9 pandemi,3. The pThe aspect of blood transfusion might have suffered most conspicuously from the social distancing policy and people’s reluctance to visit healthcare centers, as reflected by the drastic decrease in healthy blood donors visiting the blood donation centers ,11,12,13However, only a few studies have examined whether the changing environment of blood banks due to the COVID-19 pandemic affected blood usage and transfusion patterns. Therefore, we aimed to systematically analyze the changes in blood consumption and determine which factors were predominantly affected by the pandemic. Furthermore, the prognosis of the patients was also analyzed to determine how these changes affected patient outcomes.We performed a retrospective descriptive study of 2-year data. The data were obtained from a blood bank supporting an 830-bedded tertiary care academic hospital in Anyang, South Korea. To assess the impact of the COVID-19 pandemic on the blood usage patterns of the hospital, the period from March 2020 to February 2021 was set as the study period—“year 2020.” The study period was compared with the same period in the previous year, i.e., from March 2019 to February 2020, which was set as the control period—“year 2019.” All the patients who received blood transfusion during the study period were eligible for inclusion. The study was approved by the Institutional Review Board (IRB) of the Hallym University Sacred Heart Hospital (IRB No. 2021-06-018).The records of all transfused patients admitted to our hospital between 1 March 2019 and 28 February 2021 were reviewed. Data were extracted from the Hallym Smart Clinical Data Warehouse, which is a longitudinal de-identified database of patients admitted to the Hallym University Sacred Hospital established in 2011. The following data were collected: ward, age, sex, diagnosis, operation name, admission date, discharge date, date of transfused patient’s death, and number of issued blood components. The length of hospital stay was calculated by subtracting the admission date from the discharge date. Data of the total number of outpatients and inpatients over 4 years were also included to track the changes in transfusion rates among the patient groups over time.To analyze blood component usage by hospital departments and wards, the hospital departments were divided into seven main categories: the intensive care unit (ICU), surgical department, hematology, general medicine, emergency medicine, COVID-19, and others. The COVID-19 category was included in the 2020 analysis to understand the blood component usage for COVID-19 patients. The ICU category included medical, surgical, neonatal, neurological, cardiac, and emergency ICUs. The surgical department category included the outpatient departments that provided surgery or other treatment modalities and inpatient departments, such as orthopedic surgery, urology, spinal surgery, neurosurgery, thoracic surgery, obstetrics and gynecology, general surgery, otolaryngology, ophthalmology, oral surgery, and plastic surgery. Internal medicine was classified under general medicine, and hematology was classified as a separate category, as blood consumption was significantly higher in the hematology department than in the other departments. To analyze the changes in the usage of blood components, total blood was divided into red blood cells (RBCs), platelet concentrates , plateletpheresis (PP), fresh frozen plasma (FFP), and cryoprecipitate (CRYO).Since 2009, the Korean medical insurance system implemented a fee-addition system whereby a certain percentage or score is added to the prescribed treatment fee to compensate for differences in resources, financial difficulties, and characteristics of medical institutions . Some oft-test was employed after confirming the normality using the Shapiro–Wilk test. Levene’s test was performed to assess the equality of variance. The Mann–Whitney U test, a nonparametric test, was used for variables with a count of 30 or less. The 95% confidence interval of a proportion is calculated using the hybrid Wilson/Brown method [p < 0.05.Statistical analyses were performed using SPSS , R studio 4.1.0 , and Prism 8.0 . Categorical variables were compared using the chi-square test. For continuous variables, Student’s n method . The effIn 2020, a total of 32,050 blood components were transfused to 2877 patients at our center, representing a 15.8% decrease in transfused units  and an 11.8% decrease in transfused patients (3261 patients versus 2877 patients), when compared to the rates in 2019. The total number of inpatients in 2019 was 261,920, and the total number of inpatients in 2020 was 236,915, corresponding to a decrease of 9.5%. The decrease in the number of transfusions was greater than the decrease in the number of patients.p = 0.043). The data of blood components transfused in the last 4 years were analyzed . Next, the surgeries were divided into major and minor surgery, and the changes in usage by blood components were analyzed. There was no significant difference in the postoperative use of total blood components  between major and minor surgeries between 2019 and 2020. However, analysis by blood component revealed a difference in postoperative RBC usage (p = 0.030).As the largest change in blood consumption was observed in the surgery department, we analyzed the blood consumption data according to the phase of surgery: preoperative, intraoperative, and postoperative . TransfuBC usage . The posp = 0.2814). The length of hospital stay and mortality were analyzed to determine whether changes in postoperative transfusion rates affected patient prognosis. The length of hospital stay of the patients who underwent postoperative transfusion in 2019 (n = 197) was 13.97 ± 11.95 days, which was not significantly different from that in 2020 (n = 167), i.e., 16.44 ± 17.90 days (p = 0.118) (p = 0.920). Regarding mortality, among nine patients who died in 2019, two cases died after surgery, and the remaining were found to have died after discharge. In 2020, two out of eight patients died after surgery, and the remaining deaths were not directly related to surgery. In the analysis of mortality and length of hospital stay according to major surgery and minor surgery, there was no significant difference between the groups  and 2020 (62.02 ± 17.61) (= 0.118) . In 2019e groups .p = 0.1194). The transfusion rate for major surgery was 10.6% in 2019; however, it significantly decreased to 8.8% in 2020 (p = 0.017). The transfusion rate for cardiac surgery also significantly reduced .To determine whether the changes in blood usage from 2019 to 2020 were due to the changes in transfusion rates during surgery, the surgeries performed and the transfusion rates in 2019 and 2020 were analyzed . In 2019p = 0.0093). The transfusion rate for minor surgery was 7.6% in 2019 and 7.3% in 2020 (p = 0.523).For minor surgeries, in 2019, of 1,103,612 hospitalized patients, 9542 (0.86%) underwent minor surgeries, and in 2020, of 1,025,372 hospitalized patients, 8530 (0.83%) underwent minor surgeries. There was a significant reduction in the proportion of minor surgical patients between the 2 years (p = 0.014). The RBC transfusion rate had also decreased for musculoskeletal, cardiovascular, and male genitalia surgeries. When the type of surgery was categorized by organ , the RBCIn this study, we analyzed the blood consumption trends at our hospital during the COVID-19 pandemic and found that the amount of blood consumption had decreased, especially in the surgical department. Moreover, the postoperative transfusion rate had decreased significantly. Regarding blood components, RBC transfusion in minor surgeries showed the highest decline in 2020. Regarding the prognosis of patients who underwent postoperative transfusion, there were no significant changes in the lengths of stay and mortality rates between 2019 and 2020.p = 0.017). Furthermore, unlike in the study by Velázquez-Kennedy, [A previous study on the use of blood transfusion during the COVID-19 outbreak found that blood consumption was reduced by 50.2% in surgical departments. . The decKennedy, , only a Perioperative transfusion can be divided into preoperative, intraoperative, and postoperative, depending on the time of transfusion. Perioperative transfusions aim to enhance the oxygen-carrying capacity, improve hemostasis, and maintain the volume support of cardiac output. . A task In the case of perioperative blood management, there are many possible interventions other than transfusion. Iron deficiency is typically the main cause of anemia. In patients with chronic disease-related anemia, intravenous iron therapy can enhance hemoglobin concentration, functional performance, and quality of life by avoiding these hepcidin-mediated pathways ,26. InteA recent prospective randomized trial showed that postoperative intravenous infusion of ferric carboxymaltose significantly improved hemoglobin and ferritin concentrations, decreased the transfusion rate, and shortened the length of hospital stay . In a reThe Jehovah’s Witnesses, a group of more than 8.5 million individuals worldwide, need special consideration for perioperative blood management because they typically reject blood and blood product transfusions . Once seIn our study, postoperative RBC usage in minor surgeries decreased significantly in 2020 compared to that in 2019. We did not analyze interventions other than blood transfusion in the postoperative period. However, given the “more serious, first serve” concept of prioritization of blood use, the decrease in postoperative transfusions in minor surgeries can be interpreted as the clinician’s response to the insufficient blood supply. As there was no significant difference in the length of hospital stay and mortality of postoperative patients between the 2 years, we considered that the blood products were used efficiently. Due to the lack of blood supply, limited blood products had to be administered based on priority. Minor surgery, in which the disease severity was anticipated to be modest, was the most affected by blood shortage. This indicates that there has been a tendency to overuse blood products previously, and it may be used as evidence to support the idea that reducing inappropriate blood transfusion would not affect the patient’s prognosis. Our findings are also expected to provide basic data for the proper inventory management of blood banks in the lack of blood situation.Transfusions and transfusion rates were already lower in 2019 than in 2017–2018. Currently, Korea is an aged society . The sharp decline in the blood donor population due to changes in the demographic structure is a major problem in the Korean society. In a context of chronic blood inventory shortage, the shortage was exacerbated by the COVID-19 pandemic. On 20 January 2020, Korea had its first COVID-19-confirmed patient, and since then, the number of confirmed patients has increased exponentially. As a result, due to implementation of the social distancing policy and people’s psychological reluctance to go outside, the blood donation rate has sharply decreased, resulting in a significant decrease in domestic blood product reserves. The average amount of blood products in February 2019 was 19,664 ± 3526, and the average amount of blood products in March 2020 was 16,767 ± 2426, showing a 14.7% decrease. The shortage of blood inventory was thought to be worse in medical institutions’ blood centers.This study had some limitations. First, the need for transfusion is usually determined by laboratory results, such as hemoglobin concentration, platelet count, and prothrombin time, as well as the clinical condition of the patient. However, since the laboratory test results were not analyzed in this study, it was impossible to confirm whether the transfusion rate in 2020 was lower than that in 2019 due to differences in patient’s disease severity or whether the actual transfusion rate was reduced for similar levels of disease severity. Instead, the proportion of patients who underwent major surgery did not change between 2019 and 2020; therefore, it can be indirectly inferred that there was no major difference in disease severity between the 2 years. Second, the relationship between the actual transfusion of blood products and the need for transfusion in each patient was not analyzed in this study. Our hospital’s blood transfusion policy is to transfuse blood products as much as possible to patients who received a prescription for transfusion, assuming that there is no shortage of blood products. RBC preparations are transfused when the hemoglobin level is <7.0 g/dL. Even if the hemoglobin level is >7.0 g/dL and the patient has active bleeding or extracorporeal membrane oxygenation is applied, RBCs are transfused. However, identifying patients who have received blood transfusion prescriptions but have not actually received blood products can provide practical information on the blood shortage situation. Finally, this retrospective study included a single tertiary care institution, and this may limit the applicability of the results to other types of institutions with different blood bank policies and different patient compositions. Multicenter prospective studies can help address the generalizability issues.In conclusion, since the COVID-19 pandemic aggravated the blood supply shortage, blood usage decreased for minor surgeries, especially postoperative transfusions; however, patient prognosis was not affected.


Radiotherapy (RT) treatment in head and neck cancer (HNC) patients may induce long-term sequels as pain, which nowadays is not fully understand. Therefore, there is a need of characterization of pain features in HNC to enhance after oncology treatment management. Head and neck cancer survivors develop chronic pain after radiotherapy treatment. The purpose of the current study is to evaluate the presence of pain, pain distribution, and pain processing by means of patient reported outcomes and quantitative sensory testing.Pain pressure threshold (PPT), temporal summation (TS), Brief Pain Inventory (BPI), Widespread Pain Index (WPI), The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and EuroQol5D5L were assessed in 20 head and neck cancer survivors (sHNC) and 20 health-related sex and age-matched controls.The sHNC present lower PPT values in both the affected and non-affected side than did the healthy controls, especially in the widespread pain in the body, an altered TS in both affected and non-affected side and lower scores in quality of life and arm dysfunction.Following radiotherapy treatment after 1 year, sHNC present widespread pain, hypersensitivity in the radiated area, altered pain processing, upper limb affection, and a QoL diminution. These data provide evidence that a peripheral and central sensitization is happening in sHNC. Future efforts should focus on preventing pain after oncologic treatment. The comprehension about pain and its features in sHNC enhance health professional understanding and allows to tailor an optimal patient-targeted pain treatment. Head and neck cancer (HNC) includes the malignant tumors mainly related to squamous cell carcinomas of the oral cavity, pharynx, and larynx being the seventh most common cancer worldwide in 2018 .Ionizing irradiation causes damage in normal tissues located in the field of radiation; in this line, HNC patients use to cope with radiation-related changes in the oral mucosa, salivary glands, taste, dentition, periodontium, bone, muscles, and joints effects. These adverse effects include oral mucositis, fatigue, facial disfiguration, and functional impairments related to eating, swallowing, and speaking . AdditioThose early and late sequelae of head and neck cancer patients have a large impact on the quality of life, but surprisingly, the pathogenesis of many of the oral sequelae of head and neck RT is not fully understood. Concretely, the innervation and the presence of various anatomical structures in a confined space can partially explain the values of pain in HNC. While some of the short-term sequelae naturally disappear, persistent pain can be present in 8 to 60% of head and neck cancer survivors (sHNC) [Despite significant clinical relevance, chronic pain in sHNC seems to be under-considered and under-treated in long-term survivors, with some critical issues that some authors have pointed out . First, To clarify the pain profile in this setting through detailed description of how patients report the presence, distribution and processing of pain may provide indications that can have implications for clinical practice and research . For thiEligible patients were ≥ 18 years of age, had a diagnosis of head and neck cancer, had completed RT and/or chemotherapy treatment 1 year prior to assessment, and were able to read and verbally communicate with the interviewer. Subjects reporting dementia or mental illness were excluded.A control group was formed by healthy age- and sex-matched volunteers who responded to advertisements. They were excluded if they have suffered cancer or if they had any systemic disease.The study was approved by the Biomedical Ethic Investigation Committee of Granada (Spain). Patients were recruited from the Radiotherapy Service of San Cecilio University Hospital , from November 2021 to June 2022, and conducted in accordance with the Declaration of Helsinki . All patPatients completed a demographic questionnaire concerning sex, age, race, and severity of pain. Medical records were reviewed for disease and treatment information as tumor location, cancer stage at evaluation, coadjutant treatment, and medication consumption.The Brief Pain Inventory (BPI) measures both pain intensity and pain interference. The values range from 0 to 10, being 0 “no pain” and 10 “imaginable worst pain.” It also assesses pain relief, pain quality, and patient perception of the cause of pain [The Widespread Pain Index (WPI) measures body pain presence in 19 body regions over the last 7 days. One point is added for each body area where the patient refers to pain. Higher scores indicate higher pain dispersion .2 rubber tip and a range from 0 to 12 kg. The tip was placed over a pre-defined point and continuous pressure of 1 kg/s was applied until the subject reported when the sensation of pressure changed into pain. This process was first applied at the forearm to verify that the subject had understood it [PPT was measured by means of a hand-held pressure algometer (Model Mark-10 M3-20 Series) which has a 1-cmstood it .This testing was assessed bilaterally at eight points: trapezius, temporal, masseter, zygapophysial joint C5-C6, supraclavicular fossa, carpal tunnel, and anterior tibial. In healthy subjects, the affected side was taken as the irradiated homolateral side, while the contralateral side was taken as the healthy side. They were defined as proximal points within the diagnostic area of head and neck and distal points those located at distance. Three measurements were conducted, and the mean PPT was calculated –16.TS was assessed in both left and right extensor digitorum. That pressure was applied repeatedly and continuously 15 times in the same location in the forearm, during 3 and 5 s. The patient’s pain was reported by asking how much pain the patient was experiencing from 0 to 100, being 0 “no pain” and 100 “worst pain at all” .The EuroQol5D5L is a questionnaire consisting of a system of five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression, and a thermometer-like visual analog scale (VAS) anchored by 0 “worst imaginable health” and 100 “best imaginable health.” Responses to these items can be converted into a single measure of health utility using preference-based weights .The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire uses a system of 30 items, where patients attribute scores from 1 to 5. Higher scores reflect higher disability .t-test was used, and for nonparametric variables, the Mann-Whitney test was used.The data obtained from the evaluations were stored in an Excel database. They were analyzed using the Statistical Package for Social Sciences (SPSS) for Windows . The normality of the data was assessed using the Kolmogorov-Semirnov test, while the homogeneity of variances was determined using Fisher’s test. For data with normal distribution, the Student’s p < .05 was used for significant differences.Nominal values were expressed as frequencies and percentages. For continuous variables, they were expressed as mean and standard deviation. A value of A total of 20 sHNC and 20 healthy-matched controls participated on the study. Figure The characteristics of the participants are summarized in Table The results of the EuroQol-5D, WPI, BPI, and DASH of both group of subjects are presented at Table p = .05), pain (p = .008), and anxiety-depression (p = .01). The VAS presented a significantly lower result (p < .001) in the sHNC group (72.84 ± 22.56) than the control group (99.16 ± 2.89).The EuroQol-5D5L showed significant differences between groups for the subscales: activities of daily living (p = .022) and the total score (p = .04). Twenty-five percent of the sHNC showed a lower pain of 4/10; meanwhile, only 5% of the healthy subjects presented a lower pain of 4/10.For the BPI, sHNC group showed higher scores than the control group, presenting significant results for severity  than the control group (0.42 ± 0.90), with a significance of The regions with referred pain are represented in Fig. p = 0.028) between groups, where higher values relate to higher interference with daily life.DASH scale shows a significant difference  between groups. No significant differences were seen between sHNC and the healthy subjects in both affected and unaffected sites in the anterior tibialis and carpal tunnel.The results of the PPTs are presented in Table In the proximal area of the affected site, the lowest values of PPT in the sHNC were found in the masseter (1.35 ± 0.49), temporalis (1.79 ± 0.83), and supraclavicular fossa (1.79 ± 1.22). The highest PPT values were found in the anterior tibialis (5.16 ± 2.29) and in the carpal tunnel (4.33 ± 2.31). Same pattern was found in the unaffected site in the sHNC group.2, and the forearm of the unaffected side showed a mean of 3.04 ± 1.60 kg/cm2. The control group showed a mean of 4.65 ± 1.28 kg/cm2 in the affected side and 4.75 ± 1.33 kg/cm2 in the unaffected side.Figure p ≤ .001). TS showed a slightly upward progression trend, with a rapid decrease in patient-reported pain values once the latency was assessed.TS values were higher in the sHNC at any evaluation point compared to healthy subjects, being significative all of them , and temporal summation (TS). In this line, we developed the pain assessment in sHNC using self-reported outcomes and quantitative sensory tests in order to submit as much information as possible about pain features in this population. Our results confirmed a higher presence of pain in sHNC patients, with a generalized distribution and accompanied by disturbed pain processing.Overall, HNC patients continued to have pain 1 year after RT treatment, reaching a 75% of them presenting moderate-to-severe pain. Other studies developed on cancer survivors 1 year after diagnosis, reported more than 90% of patients with short-term pain symptoms related to their cancer or its treatment of whom more than 6% of adult cancer survivors reported pain intensity as “quite a bit/very much” 5 to 6 years post-diagnosis , 21. ThoThe most frequently reported areas of pain were neck, shoulder, forearm, and low-back, although generalized pain was also present. Our results are not consistent with the ones reported by Chua et al., where pain was only related to the tumor site area. This may be to their chosen sample, where more than 60% of sHNC had advanced tumor stage, compared to 5% of the sample in our study .The results after the evaluation reveal that, compared with healthy controls, sHNC have lower PPT values in both affected and unaffected hemi-body in head, neck, shoulder, and arm. sHNC also respond to a wind-up phenomenon compared to healthy subjects and show a widespread distribution of pain, which is not limited to the radiated areas. The radiated area  was the most affected site in sHNC, while no significant differences were found in distal sites .Compared to controls, widespread pressure hypersensitivity on both upper limb sides was detected in the sHNC with chronic pain. Other authors report similar findings in breast and colon cancer survivors , 25.A randomized clinical trial carried out by Ortiz-Comino reported lower PPT values with significant differences among a healthy group in trigger points located in both proximal and distal sites . This difference may be due to their high percentage (90%) of subjects receiving combined treatment of RT and surgery for tumor removing, versus the 10% of the subjects receiving it in our study. Neck dissection is a comorbid condition which can lead to postoperative pain and the maintaining of peripheral sensitization . The preWhen considering Qol 1 year after RT treatment, pain presence is still severe and can interfere in patients QoL. Additionally, other pain-related aspects in cancer patients have been proposed as relevant when exploring Qol like medication intake and psychoemotional distress , 28.The values of the EuroQol5D5L reflect that the sHNC patients have poorer health-related quality of life. This can be due to the presence of pain, the high percentage of medication intake (about 90%), and the elevated scores in anxiety and depression. In a study conducted by Deschuymer et al., the authors found results in the same line than ours in breast cancer survivors who had received oncological treatment . While tWe found arm disability significantly impaired in sHNC compared to healthy subjects. Several studies have shown upper limb functional affection in HNC patients, especially shoulder-related function . It is bTS was evaluated in both affected and non-affected side. sHNC referred that higher pain values were repetitive stimuli applied over the forearm. A significative difference related to TS differences between sHNC and healthy groups was found. Although assessing TS is a reliable way to evaluate altered pain processing, no studies in HNC patients were found to evaluate it. It has been proven to be a valid tool in other pathologies involving chronic pain as breast and endometrial cancer, hip arthroplasty, or fibromyalgia –34.Since this was a cross-sectional design, it was not possible to establish cause-effect relationships and thus the contribution of treatment to the sensitization. In further studies, an evaluation before and after radiation treatment would be interesting to assess changes in pain over time. Moreover, the sHNC had different stages of disease, different location, and underwent different types of radiation treatments at the time of the evaluation. In the upcoming studies, pain may be studied in different groups of sHNC. Also, the present work presents a small sample of subjects, so studies with a larger number of sHNC should be carried out.Radiation treatment may induce sensitization processes over sHNC, so further medical interventions must be made in order to reduce its effects. Pain in head, neck, and upper limb that appears after curative treatment could be treated. Multimodal interventions as physical therapy, exercise, and lifestyle changes help reducing the sensitization that occurs in sHNC. The knowledge of features of pain in this population could be of interest for applying the adequate dose and frequency of treatments by different health professionals.The present work reveals the existence of chronic pain, decrease PP values, an existing wind-up ratio process, and widespread pain in sHNC who underwent RT compared to healthy matched subjects. Hypersensitivity and hyperalgesia are present, suggesting, both peripheral and CS mechanisms in sHNC.


APAF1) within HH1 that was associated with a decrease in conception rate and an increase in abortion in Holstein dairy cattle. The genotype of the SR case was A/A, and most of the 1,142 normal Holstein dairy cattle tested as a control group had the genotype G/G. In addition, the A/A genotype did not exist in the control group. Based on the pathological, genetic, and radiological findings, the congenital abnormalities observed were diagnosed as SR.Schistosomus reflexus (SR) is one of the most common congenital anomalies found in cases of cattle dystocia; this disorder occurs mostly in cattle. Congenital anomalies such as SR are caused by various genetic and environmental factors, but no specific cause has been elucidated for SR. This study reports a case of SR in a Holstein dairy cattle fetus with congenital anomalies in Korea. Grossly, a distinct spine curvature was observed between the thoracic and lumbar vertebrae, accompanied by a consequential malformation from the sacrum to the occipital bone. Furthermore, the thoracic and abdominal organs were exposed. In computed tomography (CT) images, mild and severe kyphoscoliosis was observed in T1~11 and L1~6, respectively. Additionally, vertebral dysplasia was observed in S1~5 and Cd 1~5. To pinpoint the causal genes and mutations, we leveraged a custom 50K Hanwoo SNP-Chip and the Online Mendelian Inheritance in Animals (OMIA) database. As a result, we identified a nonsense mutation in apoptotic protease activating factor 1 ( Lepidochelys olivacea) (Schistosomus reflexus (SR) is the most form of common congenital anomaly found in cases of cattle dystocia; it occurs mainly in cattle, but is also common in other domesticated animals. The prevalence rate of this fatal congenital syndrome ranges from as low as 0.01% to as high as 1.3% of dystocia cases . SR occulivacea) . The mailivacea) .TGFB2) and beta 3 (TGFB3), paired-like homeodomain transcription factor 2 (PITX2), and activator protein 2 (AP2) (THAS) gene on the X chromosome has been reported in humans  –12. Secon humans , 14. VerA Holstein (pure breed) dam had a stillbirth of twins on the 220th day of pregnancy. One fetus had a crown–rump length of 67 cm, a body weight of 14.5 kg, and no specific problems on gross observation. However, the other fetus showed congenital abnormalities. Gross findings indicated full exposure of the thoracoabdominal organs; this observation was followed by additional computed tomography (CT) scanning. Externally, the body exhibited SR with exposed abdominal organs; the spine was curved and inverted laterally and dorsoventrally, and the anterior surface of the posterior limb was directed posteriorly; and the body weighed 11.6 kg . The thoIn the CT images, seven cervical vertebrae and the alignment of these vertebrae were relatively normal. Bone density in the cervical vertebral body was generally decreased, and all the endplates were unfused. There was a 1-mm-wide gap longitudinally along the central aspect of the C1 (atlas) vertebral arch  and alsoThere were six lumbar vertebrae among the lumbar, sacral, and caudal vertebrae. The vertebral curvature along the dorsal aspect of the L1-5 appeared extremely abnormal, with all the endplates unfused and five sacra with irregular margins of the vertebral body for S1-5. Overall bone density was observed to be decreased. The left sacral wing of S1 was articulated with the left iliac wing, while the right sacral wing was separated from the right iliac wing. There were 15 caudal vertebrae. The vertebral bodies of Cd1-5 had irregular margins. In the forelimb and hindlimb, the left humerus was caudodistally displaced and luxated from the left shoulder joint . The phyOur genotyping process was as follows. First, the muscle tissues of the Holstein dairy cattle calf with SR, which had been stored in a deep freezer (−78°C), were thawed, washed, chopped, and then placed in 600 μl of nuclei lysis solution. Second, total genomic DNA was extracted using a Wizard genomic DNA purification kit , following the manufacturer's instructions. Subsequently, the DNA concentration and purity were measured using a NanoDrop 1000 spectrophotometer . Finally, the genomic DNA samples were genotyped using a custom 50K Hanwoo SNP-Chip  involving 58,990 SNPs. In addition, we obtained custom 50K Hanwoo SNP-Chip data from 1,142 Holstein dairy cattle from the Animal Breeding & Genetics Division of the National Institute of Animal Science (NIAS); these data were used to confirm the genotype of normal Holstein dairy cattle as a control group for comparison with the SR case.APAF1)], which has been reported as a lethal gene for cattle, and dominant homozygous genotypes were identified for other genetic disorders. Moreover, abortion due to the haplotype HH1 genotype was identified as follows among the 1,142 normal Holstein dairy cattle: 1,108 dominant homozygous , 30 heterozygous , and 4 no genotype information (./.). The G and A allele frequencies were 98.33% and 1.31%, respectively  database. Subsequently, we summarized the data on 32 genetic disorders that were common between the OMIA database and the custom 50K Hanwoo SNP-Chip data . Additioectively . This reMost published works have reported that SR, which occurs mainly in cattle, is diagnosed through necropsy. In addition, studies on SR in various livestock species  have been reported. However, studies on ways to prevent the disorder of SR and provide opportune treatment to the pregnant dam have yet to be reported. When SR in a calf is diagnosed early, traction, embryotomy, and cesarean section are used to treat the pregnant dam. However, in cases of delayed diagnosis of SR or decayed emphysematous calves, there are instances in which the dam dies due to poor prognosis. Therefore, to prevent the death of dams, methods for early diagnosis of SR are needed.APAF1 gene. The APAF1 gene is an essential molecule in the cytochrome-c-mediated apoptosis cascade and has been directly implicated in developmental and neurodegenerative disorders. Embryos with these homozygous gene knockouts have been found to die by 16.5 days of development  was identified in HH1, previously reported in the OMIA database as a lethal gene that causes abortion in Holstein dairy cattle. If additional SR cases are observed in Korea in thefuture, we will identify genetic mutations in the whole genome using re-sequencing and SNP-Chip data.The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author.This study is only field case not the animal experiments with infection. Written informed consent was obtained from the owners for the participation of their animals in this study. Written informed consent was obtained from the participant/patient(s) for the publication of this case report.WP and KL designed and performed the research, analyzed the data, and wrote the manuscript. CD and JL provided and analyzed the SNP-Chip data. JK worked on the pathological examination. HJ and TL worked on the chromatography examination and imaging diagnostics. K-CL provided technical comments on the imaging diagnostics. KL handled technical matters for pathology and imaging. H-HC and DL interpreted the results and finalized the manuscript. All authors read and approved the final manuscript.