Tea is an important beverage in humans’ daily lives. For a long time, tea grade identification relied on sensory evaluation, which requires professional knowledge, so is difficult and troublesome for laypersons. Tea chemical component detection usually involves a series of procedures and multiple steps to obtain the final results. As such, a simple, rapid, and reliable method to judge the quality of tea is needed. Here, we propose a quick method that combines ultraviolet (UV) spectra and color difference to classify tea. The operations are simple and do not involve complex pretreatment. Each method requires only a few seconds for sample detection. In this study, famous Chinese green tea, Huangshan Maofeng, was selected. The traditional detection results of tea chemical components could not be used to directly determine tea grade. Then, digital instrument methods, UV spectrometry and colorimetry, were applied. The principal component analysis (PCA) plots of the single and combined signals of these two instruments showed that samples could be arranged according to grade. The combined signal PCA plot performed better with the sample grade descending in clockwise order. For grade prediction, the random forest (RF) model produced a better effect than the support vector machine (SVM) and the SVM + RF model. In the RF model, the training and testing accuracies of the combined signal were all 1. The grades of all samples were correctly predicted. From the above, the UV spectrum combined with color difference can be used to quickly and accurately classify the grade of Huangshan Maofeng tea. This method considerably increases the convenience of tea grade identification. With the improvement in living standards, people have started to focus on health concepts. Many studies have reported that tea provides some apparent functions, such as preventing cancer , lowerinHuangshan Maofeng tea, a green tea, is one of the ten famous teas in China. Six grades are used to indicate quality. The types and contents of the chemical components in different grades are quite alike. Traditionally, discrimination of tea quality was mainly dependent on chemical detection and sensory evaluation. However, the former is time-consuming and laborious. The results of sensory evaluation are easily affected by individual differences. Therefore, a fast and straightforward method is needed to objectively and fairly assess tea quality.Chemical component detection and sensory evaluation of different grades of tea samples;Obtaining the color difference and UV spectrum data;The classification and recognition effects of single signals and combined signals combined with principal component analysis (PCA), support vector machine (SVM), random forest (RF), SVM + RF models for tea were compared.Many modern instruments are used in tea quality identification. Hyperspectral imaging ,6, the eThe histogram in In the colorimetry results, the negative values of Δa are indicated in green and red indicates positive values. The positive value of Δb indicates the yellowness of tea liquid; the negative values are indicated in blue. The value of ΔL indicates the brightness of the liquid. ΔE and ΔE cmc represent the total color difference and ellipse ΔE formula, respectively. A three-dimensional diagram a, was drThe characteristics of the UV spectrum and color difference were extracted and combined. A new set of two-dimensional data was formed. The first two extracted principles represented 73.60% of the primary information. A PCA plot is shown in SVM, RF, and SVM combined with RF models were constructed for tea grade identification based on the UV spectrum, color difference, and combined signals. The total samples were divided into a training set and a testing set by stratified sampling. The training set accounted for 90% of the data set. To obtain more accurate classification results, we used 10-fold crosses validation to find each model’s optimum parameters. For constructing the SVM model, the penalty parameter C and kernel parameter gamma were in the range of 0 to 50. The best combination of C and gamma was based on the best classification accuracy of 10-fold crosses validation. For RF model settings, the number of decision trees was searched from 1 to 100. The best decision tree was based on the best classification accuracy. For the SVM + RF model, C and gamma ranged from 0 to 50, and decision trees were searched from 1 to 100.The accuracies of the three models are listed in The results of sensory evaluation showed that the total sensory score of higher-grade samples was higher. Generally, the higher the tea’s grade, the better the taste. In terms of the contents of chemical components, water extract, amino acids, and caffeine were higher in lower-grade samples because the raw material (buds and leaves) of high-grade Huangshan Maofeng tea are more tender. For catechins monomers, the content of EGCG was the highest in all samples. EGCG, EGC, ECG, and EC represent the main catechins in green tea ,20. The Digital instrument detection results can be used to classify tea grade. PCA has been widely used in grade identification of tea. The PCA plot of the single signal UV Spectrum showed samples were arranged linearly by grade. However, samples of adjacent grades overlapped. The PCA plot of the single-signal color difference separated three grades of samples: S1, S2, and S3. These three higher-grade samples were located in the lower-left corner of the region. Lower-grade samples were located in the upper-right corner of the plot and had some overlaps. The PCA plot of the combined signal showed samples distributed with decreasing quality clockwise according to grade. The combined signal was more accurate than single signals. Other researchers also used these digital instruments for tea classification. Aboulwafa et al. found that the PCA plot of UV spectroscopic data can be used to separate two areas: low-quality Chinese tea, high-quality Chinese tea, and entire South Asian samples (from India and Sri Lanka) . DankowsThe polyphenolic compounds, glyphs, and phenolic acids are abundant in green tea, and have absorption peaks in the UV region. EGCG and ECG showed absorption peaks at 246–325 nm. Phenolic acids exemplified by gallic, chlorogenic, and caffeic acids showed absorbance maxima at 273 nm for the first and 330 nm for the last ,24. The In three prediction models, the combined signal performed the best. The combined signal had medium accuracy in the SVM model. Training and testing accuracy were 0.922 and 0.875, respectively. In the RF and SVM +RF models, the accuracies of the training and testing were all 1. The RF and SVM + RF models had the same training and testing accuracies with all signals, which had higher training accuracy than the SVM model. Studies of Huangshan Maofeng tea identification with models are lacking, but other green teas have been studied. Zhang et al. identified the grade of Xinyang Maojian tea (a kind of Chinese green tea) with SVM models, and the training and testing accuracies they reported were 86.11% and 87.5%, respectively . DankowsHuangshan Maofeng tea, a famous Chinese green tea, was collected for the experiments in this study. All samples were from Anhui province, China. The six grades included: special grade class one, special grade class two, special grade class three, grade one, grade two, and grade three. We termed these samples S1, S2, S3, G1 G2, and G3, respectively. All samples were conserved in the refrigerator at 4 °C before the experiments.In this experiment, 12 chemical components of tea were measured according to the National Standard of the People’s Republic of China. The water extract content was determined by the weight variation in the tea leaves (ISO 9768:1994). The contents of eight catechins (ISO 14502-1/2:2005) and caffeine (ISO 20727:1995) were determined by high-performance liquid chromatography . The eight catechins included epicatechin gallate (ECG), epigallocatechin gallate (EGCG), gallocatechin (GC), epigallocatechin (EGC), catechin (C), epicatechin (EC), gallocatechin gallate (GCG), and catechin gallate (CG). The total polyphenols (ISO 14502-1/2:2005) and free amino acids (GB8314-2013) were determined using UV spectroscopy .All tea samples were examined and scored by seven tea tasting panelists from the Tea Research Institute, Zhejiang University, China. The sensory evaluation procedure was followed according to the National Standard of the People’s Republic of China (GB/T 23776-2018). The total score of sensory evaluation is 100, with 25% allocated for dry tea appearance, 10% for liquor color, 25% for aroma, 30% for taste, and 10% for infused leaves. The procedure was performed as follows: the appearance of dry tea samples was first evaluated and scored; second, 150 mL of boiled water was added to a cup with 3 g of dry tea sample. After covering for 4 min, the tea infusion was filtered, and the aroma, taste, and color of the tea infusion were examined, as was the appearance of wet leaves. Finally, the total score was calculated .A microplate reader  was used for collecting UV absorption spectra of tea samples. The scanning range was 230–380 nm, and the scanning interval was 1 nm. The sample preparation was the same as in The color difference of the tea infusion was determined on an UltraScan VIS spectrophotometer. . We set the mode type as TTRAN-total transmission. The ultraviolet filter was nominal. Chalkboard and whiteboard were used for color correction. The sample preparation was the same as described in PCA is a commonly used dimension reduction method. It exports a few principal components from the original variables while retaining as much information as possible about the original variable. It can effectively reduce the dimensions of the original variables. Graphs represent the relationship between variables, which improve the efficiency of analysis ,17. SVM In this study, the UV spectrum and color difference were combined to classify the grade of Huangshan Maofeng tea. The combination of these two factors, instead of sensory evaluation, outputs digital results to ensure the objectivity of the tea grade identification. Compared to complex detection of chemical components, this method does not require pretreatment—the use of the tea infusion is sufficient—thereby considerably accelerating the efficiency with high accuracy rates. To classify Huangshan Maofeng tea, the combined signal was more accurate than the single-signal UV spectrum and the single-signal color difference. The combined signal’s PCA plot effectively separated samples according to grade, and showed a regular distribution of decreasing quality in the clockwise direction. In terms of discrimination of quality, the RF model was more suitable. The training accuracy was 1 for all signals and the testing accuracy of the combined signal was 1. With the advantages of fast detection and accurate classification, UV spectrum and color difference combined the with RF model can be used as an effective method for tea quality identification. In the future, it can be applied to other kinds of teas, such as black tea, dark tea, and so on.An application for patent has been submitted to the National Intellectual Property Administration, PRC. The patent application number is 202010744113.8.


In proteomics, to improve our understanding of the mechanisms of malonylation at the molecular level,the identification of malonylation sites via an efficient methodology is essential. However, experimental identification of malonylated substrates via mass spectrometry is time-consuming, labor-intensive, and expensive. Although numerous methods have been developed to predict malonylation sites in mammalian proteins, the computational resource for identifying plant malonylation sites is very limited. In this study, a hybrid model incorporating multiple convolutional neural networks (CNNs) with physicochemical properties, evolutionary information,and sequenced-based features was developed for identifying protein malonylation sites in mammals. For plant malonylation, multiple CNNs and random forests were integrated into a secondary modeling phase using a support vector machine. The independent testing has demonstrated that the mammalian and plant malonylation models can yield the area under the receiver operating characteristic curves (AUC) at 0.943 and 0.772, respectively. The proposed scheme has been implemented as a web-based tool, Kmalo ( Several studies have indicated that PTMs play critical roles in regulating cellular functions and are related to a lot of disease progression5. For instance, type 2 diabetes has been reported to be regulated by malonylation, particularly the pathways associated with fatty acid metabolism and the glucose6. Both mitochondrial and enzymes urea cycle have been shown to be regulated by protein malonylation7. Additionally, it is confirmed that lysine malonylation is a new type of histone PTM and the unusual modification of histones induces diseases, such as cancer8. In plants, malonylation has been shown to be a critical reaction in the metabolisms of xenobiotic phenolic glucosides in tobacco and Arabidopsis9. Meanwhile, previous experiments targeting lysine malonylaome in Oryza sativa and Triticum aestivum L. have demonstrated a dominate presence of malonylated proteins in the metabolic processes which include the tricarboxylic acid (TCA) cycle, carbon metabolisms, photosynthesis, and glycolysis/gluconeogenesis11.Lysine malonylation , a reversible post-translational modifications (PTMs), can be identified by mass spectrometry and database searchingM. musculus proteins12. Specifically, the support vector machine (SVM) and minimum redundancy maximum relevance (mRMR) technique were adopted to develop the prediction model by considering features from the peptide fragments, including the position specific amino acid propensity, sequence order information, and physicochemical properties. Xiang et al. used pseudo amino acids as features to construct an SVM-based classifier13. Wang et al. took multiple organisms into consideration to build a novel online prediction tool, MaloPred, for the identification of malonylation sites in E.coli, M. musculus, and H. sapiens, separately, by integrating not only protein sequence information and physicochemical properties, but also evolutionarily similar features14. Taherzadeh et al. further investigated whether different species require different prediction models to maximize the accuracy15. By training the models using data from mice and testing them on other species, they found similar underlying physicochemical mechanisms between mice and humans, but not between mice and bacteria. It should be noted that their SVM-based web server, SPRINT-Mal, was the first online malonylation sites prediction tool to take into account the predicted structural properties of the proteins. Zhang et al. provided systematic comparisons of sequence-based features, physicochemical-property-based features, and evolutionary-derived features in the identification of Kmal sites for E. coli, M. musculus, and H. sapiens, respectively16. Random forest (RF), SVM, LightGBM, K-nearest neighbor (KNN), and logistic regression (LR) were adopted to generate optimal feature sets. The integration of the single-method-based models through ensemble learning was found to improve the prediction performance in independent tests. Ahmed et al. proposed a new hybrid resampling method for highly imbalanced data17. Furthermore, deep learning approach has recently been widely applied to biological sequence analysis21. Chen et al. first constructed an integration of the deep learning model based on long short-term memory (LSTM) with an RF classifier for the prediction of mammalian malonylation sites22. Due to the strong capability of the deep learning methodology to learn sparse representation, this methodology showed a superior performance compared to traditional machine learning model. In addition to the malonylation site, many computational methods have been developed for the prediction of various PTM sites based on protein sequences28.A number of computational methods have been introduced to predict malonylation sites based on machine learning approaches. Xu et al. developed the first web-server, Mal-Lys, to predict Kmal sites for To improve our understanding of the mechanism of malonylation, it is necessary to identify the malonylation sites accurately in advance. However, the experimental identification was mainly performed using mass spectrometry, which is time-consuming, labor-intensive, and expensive. Computational approaches could be used to effectively and accurately identify malonylation sites. Currently, existing computational approaches mostly rely on feature engineering, while deep learning is capable of excavating the underlying characteristics from a large-scale training dataset. Additionally, although the biological functions of malonylation in plants require attention, the currently existing tools have only taken into account malonylation sites in humans, mice, and bacteria. An efficient methodology for the identification of malonylation sites in more organisms would greatly improve the understanding of the mechanisms of malonylation. Therefore, the primary purpose of this study was to develop hybrid models combining CNN and machine learning algorithms for the prediction of malonylation sites in mammals and plants, respectively. Meanwhile, a user-friendly web tool, which includes an optimal classifier, was established for individual use in the identification of malonylation sites.As shown in Fig. 29. In Supplementary Fig. 30 of malonylation and non-malonylation peptides, the enrichment of amino acids neighboring the malonylation sites across species was observed. Lysine (K) was found to be significantly enriched at multiple positions in both H. sapiens and M. musculus proteins, particularly at positions from 1 to 19 and positions 27, 28, and 29. Meanwhile, leucine (L) was found to be depleted at positions 9, 10, and 13. On the other hand, T. aestivum proteins showed a very different pattern when compared to H. sapiens and M. musculus proteins for arginine (R) enrichment at positions 10, 12, 13, 14, 21, 28, and 29 and no evidence of serine (S) depletion. The two sample logo for H. sapiens to M. musculus, H. sapiens to T. aestivum, and M. musculus to T. aestivum is shown in Fig. T. aestivum is different from the mammals. Subsequently, the data of the H. sapiens and M. musculus proteins could be combined to build a prediction model for mammals, thereby building another prediction model for T. aestivum.WebLogo was mainly used to analyze the frequencies of occurrence of every position around the malonylation sitesPearson’s correlation coefficient (PCC) was employed to evaluate the dependency between the label and the feature in the training dataset. It should be noted that the PCC values always range from + 1 to –1. A value greater than zero denotes a positive association, whereas a value less than zero denotes a negative association. A value equal to zero indicates that there is no correlation. Therefore, the larger the absolute value of the PCC value, the stronger the correlation.The top ten PCC values of each feature in the mammalian dataset are shown in Supplementary Table In terms of plant proteins, the top ten PCC values of each feature are shown in Supplementary Table 31. Figure H. sapiens and M. musculus shared a highly common functional distribution in terms of biological processes. Both were statistically enriched in the cytosol (GO:005829), intracellular (GO:0005622), intracellular part (GO:00044424), cytoplasm (GO:0005737), and cytoplasmic part (GO:0044444). In terms of the cellular components, both H. sapiens and M. musculus were statistically enriched in the cellular metabolic process (GO:0044237). The common processes in which all three species were statistically enriched were the cytoplasm (GO:005737) and the organic substance metabolic process (GO:0071704).We used the classification system PANTHER to analyze the functional distribution of malonylated proteinsSupplementary Fig. The performance of our proposed hybrid model in mammalian proteins is shown in Table 16H. sapiens model and LEMP22, respectively. These results indicate that the model proposed here was comparable to existing other tools.We compared our model with other proposed computational prediction models. Table A web-based tool, Kmalo, has been developed to perform the prediction of protein malonylation sites. Users can predict malonylation sites in either mammalian or plant proteins. After submitting a protein in FASTA format via uploading a file or pasting the sequences into the tool, users will receive a job ID with which they can retrieve their results once the prediction process is finished. The results can be conveniently copied, printed directly, or downloaded in several formats, including CSV, XMSL, PDF. Snapshots of the tool’s website are shown in Supplementary Fig. An increasing amount of studies are currently working towards improving our understanding of the mechanism of protein lysine malonylation. The role of this post-translational modification in a wide range of cell functions has drawn the attention of many research groups. In certain biological processes, malonylation is associated with the development of disease. However, laboratory experiments for the validation of malonylation sites are often time-consuming and expensive. In this study, we proposed a machine learning-based methodology for the prediction of malonylation sites, in hopes of reducing the economic and temporal efforts required by traditional methods. To obtain potential hidden information in the sequences, we applied a deep learning-based methodology to help extract interactive information from the evolutionary information, physicochemical properties, or simply the protein fragments, which were encoded by PSSM, AAindex, and one hot vector. Then, the two commonly used features for the identification of PTM sites, AAC, and PAAC were combined with the extracted information to obtain the final features.. proposed three machine learning-based models for predicting malonylation sites in humans, mice, and bacteria separately15. They used mouse proteins to test the model trained using human proteins, and used human proteins to test the model trained using mouse proteins. Both resulted in comparatively similar performances. This suggested that malonylation in mouse and human proteins have similar physicochemical mechanisms, which is consistent with the feature analyses shown in Fig. Some previous studies have suggested building a malonylation sites prediction model for mammals using mouse and human proteins. Taherzadeh et al11. In fact, this study is the first to build a computational method for the identification of malonylation sites in plant proteins. We found that a complicated deep learning-based approach could lead to an overfitting problem. This could be due to the limited amount of data. As such, we modified our framework to make it more suitable for training only a small amount of data. After a series of experiments, we discovered that assembling the prediction results from the models trained by different features resulted in a robust model. Compared to the majority votes strategy, when combined with another SVM model, the former ensemble method resulted in a better performance.Recent studies have revealed that malonylation sites impact the functional processes not only in mouse and human cells, but also in plant cellsIn this study, we constructed hybrid models combining CNN and machine learning algorithms, including RF and SVM, in order to predict malonylation sites in mammals and plants, respectively. The competitive performance compared to the existed tools showed that the proposed hybrid scheme indeed generated useful information from raw protein sequence data. Therefore, the framework we proposed is expected to inspire others to develop novel computational methods on the related issues.We created a useful identification system for the identification of malonylation sites, represented by a flow chart of steps, as shown in Supplementary Fig. 32 and LSTM-based ensemble malonylation predictor (LEMP)22. PLMD is an online database consisting of integrated protein lysine modifications, which includes 5,013 and 4,390 validated malonylation sites from 1841 H. sapiens and 1,466 M. musculus proteins, respectively. LEMP is a newer web tool and so far contains 5,288 malonylation sites and 88,636 non-malonylation sites for the prediction of malonylation sites in mammalian proteins. On the other hand, Liu et al.10 derived plant proteins from 342 malonylation sites in 233 T. aestivum proteins.In this study, we collected the mammalian proteins from protein lysine modifications database (PLMD)33 was used to reduce the redundancy at the cutoff threshold of 40% sequence identity. Then, the proteins were segmented into a fixed-length peptide fragment with a lysine (K) located at the center, denoted as:R is any of the 20 amino acids, and n represents the distance between the residue and the central K. The number of residues upstream and downstream of the center remained equal. In other words, the window size of each peptide was 2n + 1. If the length of the upstream peptide or downstream peptide was less than n, the dummy residue “X” would be used to fill the lacking residues. In this study, we considered window sizes from 15 to 35 . Then, we used CD-HIT-2D on positive and negative data to eliminate redundancy. Since the mammalian peptides collected from LEMP were processed with a window size 31, UniProt34 was employed to map the peptides to determine their residues for window sizes 33 and 35. Therefore, the mammalian proteins were composed of LEMP and the processed PLMD data; the redundant peptides were removed. After processing, 80% of the data were randomly selected to form the training dataset for the construction of the prediction model of the malonylation sites in mammalian peptides, and the remaining 20% of the data were selected for an independent testing dataset. Similarly, the same steps were used to process the wheat peptides in PLMD data. We randomly separated the wheat data with a ratio of 7:3 for training and test data for the prediction of malonylation sites in plants. Related works suggest a window size around 25 is suitable for predicting malonylation sites in mammalian proteins. However, little related works have suggested that a varying window sizes for the development of a malonylation site prediction model in plants. Consequently, we considered window sizes ranging from 11 to 39, a wider range than that was considered for mammalian peptides. The experimental datasets are summarized in Table In order to prevent potential bias, a cluster database at a high identity with tolerance (CD-HIT)X”) surrounding the modification sites and has been widely used in various prediction works14. Here, the site itself is not counted. As a result, each segment will be encoded as a 21-dimention vector.Amino acid composition (AAC) encoding calculates the frequency of the residues (20 standard amino acids and one dummy amino acid “X”). Every position in each row was filled with “0”, except the one that corresponds to the amino acid in the column, which was filled with “1”35 . This encoding method has been applied in many kinds of PTM site prediction20.Additionally, one hot encoding was used to express the sequence features. Specifically, the peptide was encoded as a two-dimensional matrix. The rows of the matrix were the amino acids in the peptide, and the columns were the 21 amino acids  encoding was considered in this study. This group of descriptors was first proposed by Shen and Chou (2008)38 collects indices of the representing physicochemical properties of amino acids. In this study, we used iFeature37 to encode each sample peptide. For each sample, the amino acid at each position was represented by 531 physicochemical properties, such that the vector of each encoding peptide was 531 × (L–1) dimensional . Then, a feature-selection method was applied to remove the redundant properties and obtain the optimal physicochemical property sets. iFeature was used to calculate the information gain of our AAindex-based feature, which was then added to the value of information gain for each physicochemical property at each position. With the highest summed-up value of information gain, 46 physicochemical properties were selected for mammalian proteins and 30 physicochemical properties for plant proteins. After reshaping the features, a two-dimensional matrix with 46 (or 30) columns and (L–1) rows for each sample fragment was obtained.The AAindex database16. In this study, PSI-BLAST was performed with a default E-value cutoff in three iterations. The size of the profile was L × 20, where L represents the window size and 20 denotes the number of the standard amino acids. It should be noted that the PSSM profile of the fragment was directly used as the input of the deep learning model, without reshaping.Position-specific scoring matrix (PSSM) profiles have been used in several related works39 , where the number of decision trees was 500. Radial basis function kernel was chosen as the default kernel function for our SVM models. The window size of the optimal model with the highest area under the receiver operating characteristic curve (AUC) score was selected as the most suitable window size. A CNN model including two rounds of the convolutional layers and max pooling layers followed by three fully connected layers was designed. At this stage, 5 single-feature models for mammalian proteins and 5 single-feature models for plant proteins were obtained. Herein, the ‘Tensorflow’ package in Python was used.The proposed hybrid models are composed of two parts. In the first part, a series of experiments were performed to develop the best prediction model for each single-feature category. Specifically, RF, SVM, and CNN were implemented for the one hot encoding features, including the AAC, PAAC, AAindex, and PSSM profiles, respectively. It should be noted that each model was trained with peptides ranging from window size 15 to 35 in order to determine the proper length. RF models were constructed using the Python package “Scikit-learn”The second step involved the aggregation of the separated models trained with different features in order to make a final prediction. Three methodologies for aggregation were used: another neural network, SVM, and majority votes. For the mammalian proteins, considering the CNN model as a feature extractor and combined with the raw AAC, the feeding of the PAAC feature into another neural network obtained the best AUC. On the other hand, for the plant proteins, feeding the positive probability of each feature into a SVM model resulted in the best performance. The schemes of proposed model for mammalian and plant proteins are shown in Supplementary Fig. The following metrics were used to evaluate the performance of our models: sensitivity (SEN), specificity (SPE), accuracy (ACC), and Matthews correlation coefficient (MCC). The detailed definitions of these metrics are given below.The web-based prediction tool was mainly written in HyperText Markup Language (HTML), Cascading Style Sheets (CSS), JavaScript (JS), and HyperText Preprocessor (PHP). When a user submits data, this data will be saved as a text file named with a combination of the date, time, and five random characters or numbers in an automatically created folder in the server computer. A series of feature extractions will be performed and every feature will be saved as a text file in the same folder for further use. For the same reason, the prediction result will also be saved as a text file. If the user waits on the same page after having submitted their data, they will be automatically redirected to the results page. Otherwise, the user can use the job ID, with the same name as the automatically-saved input file, to retrieve his or her results.Supplementary file1 (DOCX 2063 kb)


We aimed to evaluate the diagnosis of acute toxoplasmosis by IgG avidity test in pregnant women.Toxoplasma antibodies . It was not found any correlation between the history of raw meat consumption, cats keeping, education, and residency site. Moreover, 16 people (6.4%) had IgM antibody, of which, 10 cases (62.5%) with low avidity for IgG and 1 people (6.2%) with moderate avidity and 5 cases (31.3%) with high avidity for IgG. Moreover, 76% of pregnant women were seronegative.Total prevalence of IgG and IgM was 23.2% and 7.2%, respectively. A significant correlation was observed between the mean age and IgG level  with positive IgM antibody in their serum had a low avidity for IgG which revealed an acute infection among pregnant women.  Toxoplasmosis is a protozoan infection with worldwide prevalence. This infection is zoonotic between humans and animals. More than one-third of the world's population is infected with this parasite . ToxoplaToxoplasma is different in various parts of Iran, varying from 20%–35% in southern warm and dry conditions to 72 ºC in the temperate regions of the north  and in tropical areas of Latin American, or in African sub-Sahara countries in which cats are abundant and climate is favorable for survival of oocytes , 4. In t% and in he north .The three main ways of transmission of toxoplasmosis are through consumption of raw or semi-cooked meat, contact with infected cat-feces with the oocyte, and vertical transmission. During pregnancy, the most common route of contamination is through raw consumption or uncooked meat or contaminated water, or contact with soil (gardening without gloves) or cat. Transmission of toxoplasmosis rarely takes place through blood transfusion and organ transplantation , too , 7.Toxoplasmosis is linked to the immune system. Therefore, the clinical forms of this disease are different in people with the normal immune system and people with immunodeficiency. The most noticeable clinical symptoms in affected patients are lymphadenopathy and ocular lesions, but in 90% of affected people, no specific clinical symptoms are observed . One of T. gondii antibody. Usually, to show if a person has been infected in the past, or has recently been infected; a combination of serological tests be required  during 2015 were selected after obtaining written consent and completing the checklist of their demographic data.The study was approved by Ethical Committee of Mashhad University of Medical Sciences with number of IRMUMS.fm.rec.1394.563.Toxoplasma (IgM and IgG) using direct ELISA (Euroimmun Company) instructions and samples with positive IgM antibody titer were selected and to determine the early and acute infection.Then, 1 mL of blood sample was collected for detection of toxoplasmosis. After separating the serum from blood samples by Centrifuge at 3000 rpm, sera were stored in –20. Finally, the serum samples were evaluated for the presence of antibodies anti-For each IgG and IgM ELISA methods, sera were tested and the amount of cut-off was calculated by this formula: X±2SD . The absorbance more and less than the cut off was considered as positive and negative, respectively.The IgG cut off was as follows:Negative: proportion <8 IU/mL, borderline: 11 IU/mL > proportion > 8 IU/mL, Positive: proportion> 11 IU/mL. Also, The IgM cut off was as: proportion < 0.8 IU/mL, borderline: 1.1 IU/mL > proportion > 0.8 IU/mL, Positive: proportion> 1.1 IU/mL.IgG avidity test was used and after adding the avidity buffer and using anti-human IgG and comparing the antibody titer with no adding buffer, Optical Density (OD) was measured at length wave 450 nm. And its index was reported as the percent. Then the results were analyzed using SPSS  software.agammaglobulinemia, kidney transplantation and, malignancy, or people receiving immunosuppressive drugs were excluded.All pregnant women who were in the first four months of pregnancy entered the study. Women with a history of an immunosuppressive disease, RAI< 40%: Antibodies index containing low avidityRAI 40%–60%: EquivocalRAI > 60%: Antibodies index containing high avidityTo calculate the Relative Avidity Index (RAI), the OD Value of the sample washed with urea solution divided by the OD value of the sample washed with PBST solution, multiplied by 100 (according to the kit instructions).P-value<0.05 was statistically considered as significant.For data analysis, was used of Frequency, Pearson Chi-Square, Likelihood Ratio, and Fisher Exact Tests. And P=0.83) and (P>0.52), respectively. The most cases of acute toxoplasmosis in pregnant women who referred to health centers were in the first month of childbearing and the minimum in the third month. Moreover, no significant relationship was found between IgM and IgG antibodies of Toxoplasma and history of contact with the cat (P=0.54) and (P>0.61), respectively. Toxoplasma based on the consumption of uncooked meat in pregnant women who referred to health centers.The prevalence of anti-toxoplasmosis IgG and IgM in pregnant women referred to the health centers was 23.2% and 7.2%, respectively. Moreover, the highest frequency of IgG and acute toxoplasmosis was observed in the age group of 20–30 yr. accordingly, avidity index of acute toxoplasmosis cases between the pregnant women showed that 62.5%, 6.3% and, 31.3%, respectively had low, intermediate and high avidity. No significant correlation was found between toxoplasmosis IgM and IgG with occupation (Toxoplasma and consumption of uncooked meat (P=0.39) and (P>0.38), respectively.Moreover, no significant correlation was found between IgM and IgG antibodies of Toxoplasma based on educational level in pregnant women referred to health centers is presented in Toxoplasma and educational level (P=0.82) and (P>0.69), respectively.The frequency of IgM and IgG antibodies of Toxoplasma was found a significant correlation (P=0.02), but this issue was not observed about IgM (P=0.19).As shown in T. gondii causing toxoplasmosis is an obligate intracellular protozoan parasite that has the potential to infect most warm-blooded vertebrates with the global distribution. Toxoplasmosis in people with a healthy immune system is without clinical symptoms or causes mild clinical symptoms similar to the flu symptoms (symptoms .Serologic methods in the diagnosis of toxoplasmosis have different sensitivity and specificity and implemented based on the isolation and measurement of antibody using the avidity and affinity. In the present study, there was a significant correlation between age and anti-IgG titer.In line with our results, in Tehran, Iran , and In Toxoplasma IgM and IgG had a significant relationship with education that was in line with the studies conducted in Hamadan, (Based on educational level, the prevalence of anti-Hamadan,  and KhorHamadan, .Toxoplasma, which was consistent with other results (Toxoplasma (In the current study, there was not a significant correlation between the use of raw and semi-cooked meat and IgG and IgM antibodies anti- results 18, but xoplasma . In thisxoplasma –22.toxoplasma IgG and IgM antibodies, but the prevalence of antibodies in housewives was significantly higher than those employed which was accordant with the findings in France (Moreover, there was not a significant relationship between occupation and the prevalence of anti-n France .In the present study, the most prevalence was reported in the city dwellers, but contrary to our study, in England, the highest prevalence was in rural areas .Toxoplasma and consumption of uncooked meat. The undercooked meat is the famous risk factor for toxoplasmosis, although many studies did not report a significant association (In this study, as for IgG and IgM, the results were similar to another stuy in Tehran . In the ociation , 27 but ociation . In anotociation .Considering the high rate of IgM positive people had a high rate of avidity, we cannot use IgM for the diagnosis of acute toxoplasmosis alone. So, screening for determining the IgM status and also, performing IgG avidity test for the identification of women with acute infection and need for treatment are highly recommended.Toxoplasma infection should be considered as an important factor that affects the pregnancy and IgG avidity as an important test for screening the women who need the treatment. Moreover, according to a high prevalence of seronegative pregnant women reported in this study and the possibility of acute toxoplasmosis in this group, the preventive measures should be taken.


The aim of this study was to review the evolutionary tendencies of research regarding to the study of male Rink-Hockey players´ and game performance. A systematic search was conducted in PubMed, Web of Knowledge and Scopus databases according to PRISMA method. The initial search identified 815 titles, resulting in 19 articles being included within the review. Original papers (English language) contained relevant data regarding rink hockey players’ performance or morphological/physiological demands, anthropometry/body composition characteristics were eligible. Studies were classified into categories: (1) Physiological Demands, (2) Anthropometry and Body Composition, (3) Game Characterization/Patterns, (4) Injuries. Results indicated that Rink hockey requires high intensity effort which demands both short and long duration efforts requirements from players. Body composition analysis shows to be an important monitoring tool which complements the understanding of the athlete’s cardiac adaptation. Game patterns shows a combination of specific game momentums with different outcomes according to the game zone. The intense short-term movements, collision and contact between players, in addition to the weight and speed of the hard ball and the stick, can considerably increase the risk of moderate and severe injuries. Lack of literature in Rink-Hockey is remarkable, and research is mainly focused on children and adolescents’ players. Furthermore, the existing research with adult elite athletes was assessed with a small sample size.  Rink-hockey  is an indoor intermittent team sport that requires the combination of short and long duration efforts and is considered a highly specialized and physiologically demanding sport . PlayersRegardless of rink-hockey being popular worldwide and played on five continents, there seems to be a lack of published scientific research , with onDespite the lack of scientific literature, it is well reported that rink-hockey is a high intensity intermittent sport in which non-continuous actions of different speed levels are followed by incomplete recovery periods ,9, requiThe understanding of physical and physiological demands is essential for game success, however, it is also crucial to complement athletes’ fitness traits and game characterization. As in any other invasion team sport, game analysis, and more specifically, the analysis of technical and tactical behaviors of players and teams, it is fundamental to characterize the behavioral demands of the game . To our There are constantly new approaches to improve team sports performance, such as tactical, technique, and physical conditioning . FurtherSummarizing, in the last 10 years, an increase in the number of studies has been observed in rink-hockey . HoweverA systematic search was conducted on the electronic databases PubMed, Web of Knowledge, and Scopus, according to the recommendations from the preferred reporting items for systematic and integrative reviews and meta-analysis statement (PRISMA) ,16. A seTo increase research accuracy, two reviewers  separately screened citations and abstracts to identify the articles which would potentially combine the inclusions criteria, having registered the characteristics of each study, including the name of the authors, sample, procedure and results or main outcomes. In case of disagreement regarding the eligibility of the article, a third reviewer (Hugo Sarmento) was included in order to reach a final decision. After all the articles were screened, the categories of the studies were organized into specific topics according to their main research topic.The quality of the studies was assessed as recommended in Faber et al.  using thn = 9); (2) articles regarding other sports (n = 19); (3) articles including female athletes (n = 2); and (4) articles included others sports athletes with no relevant data (n = 2). Finally, 19 articles were included for the review. A flow chart of the study selection process is shown in The initial search identified 815 titles. These data were then exported to reference manager software Mendeley . Duplicates (605) were eliminated automatically or manually. The remaining 210 were then screened for relevance based on their title and abstract information, with 159 being excluded. The remaining 51 were analyzed in more detail, and 32 papers were excluded according to the following criteria: (1) articles published in languages other than English , 31.5% from 2010 to 2014, and 5.2% before the year 2010. Regarding the quality of studies, as recommended in Faber et al.  and SarmStudies were classified into the following categories established according to the main research topics that emerged from the content analysis: (1) physiological demands, (2) anthropometric, body composition and conditional profile, (3) game characterization and games patterns, and (4) injuries. See The analyzed studies bring up information related to the characterization of specific competition level such as competitive demands of elite male rink-hockey and the influence of workload and well-being on athletes ,20 or fuBased on the analysis of the selected studies, the lack of research about this thematic in comparison with other team sports is obvious. However, Yagüe  in a stuThe practice of sports offers clear opportunities to understanding cardiac remodeling . AlthougConcerning the training environment, several factors can be considered especially relevant—therefore, the lack of conditioning coaches and the importance of multidisciplinary teams have been analyzed on both divisions in Spain (OK Liga and first division) . On the The studies that analyzed anthropometry and body compositions explored athlete´s profile to establish specific conditional profiles of rink-hockey players . Also, tVaz et al.  analyzedA sample of 23 players  were assessed during two Spanish seasons (2014–2015 and 2015–2016) to analyze the injuries of rink-hockey players by considering the level of gravity vs. the level of competition , the resmax and blood lactate performance is between 4.0 mmol/l−1 and 4.6 mmol/l−1 [max during the whole game, remaining constant throughout the entire game [−1 and 5.5–6.5 mmol/l−1 at the end of game, slightly lower than levels obtained during Yagüe et al. [−1 in the middle and 7.2 ± 1.0 mmol/l−1 at the end). Maximal effort and maximum heart rate are frequently reached in matches, therefore Yagüe [The match demands of “multiple-sports” include periods of strenuous physical activity and recovery interspersed with brief periods of sprinting ,36, but mmol/l−1 . In rinkmmol/l−1 ,39. Our mmol/l−1  tried tommol/l−1 . In lineire game . Blood le et al.  in theirre Yagüe  mention re Yagüe . −1 [It is recognized that sports training is related to the occurrence of concentric and eccentric cardiac hypertrophy . Long-te−1 . Results−1 . There a−1 ,42. Furtp < 0.05) in elite male rink-hockey players, with a large correlation between the level of ventral core strength-endurance and the time to exhaustion  [Although few studies have addressed research focused on the characterization of morphological and physiological demands of roller hockey, it seems clear that in elite rink-hockey, as in other indoor team sports , enhanci < 0.05) . Monitoring athletes´ training loads is important to understand whether they adapt to the training program and to determine their feedback through fatigue . The comIn rink-hockey athletes, training sessions during normal weeks (one game) are associated with higher loads than sessions during congested weeks (two games) as indicated by differences in volume, rated of perceived exertions (RPE), and internal training load . In termIn the few last decades, several studies in different sports have focused their attention on the anthropometric characteristics of elite athletes ,50 with p < 0.05), resulting in some cases of low energy availability in rink-hockey players. [p < 0.05) were also observed for vitamin and mineral intakes in child and adolescent rink-hockey players due to higher mean intakes in control groups [For example, the analysis of the energy intakes according to the demands of the competition on each sport, allows for an analysis of the necessary energy levels required by athlete´s for sport performance and especially for growth ,29. Withplayers. . On the l groups . This fal groups . The impl groups . Among al groups . Howeverl groups . Well-trl groups . Such rel groups ,59 and mThe indicators of FFM and FM, were simultaneous robust determinants of left ventricular mass (LVM) ,59. HoweAccording to Coelho-E-Silva et al. , the comStudies in adult male rink-hockey players are limited, and thus, those that exist consist of a small number of participants.2) (BMI), and a sum six skinfolds of 51.80 ± 14.91 mm described that a significant inverse correlations exists between vertical jumps, and linear velocity in skating  [In rink-hockey, power, strength, speed, and agility are physical qualities of extreme relevance for the physical performance of the players, as in ice hockey . Agility= –0.78) . The sam= –0.78) . The res= –0.78) . Additio= –0.78) . ConsequRink-hockey is a particular invasion team sport  because As in futsal, rink-hockey is predominantly offensive and of finishing actions, players may reach 408–422 displacements during a game ,65. NearRink-hockey is an intense collision and contact sport between players; in addition to the weight and speed of the hard ball and the stick, the risk of moderate and severe injuries can be considerable . Few stuOne of the most common chronic injuries is promoted by the impact of the Christiania stop, which induces groin pain. . KinematIn general, the results revealed that high values of adapted cardiorespiratory function of players may be important to keep elevated levels of activity during the entire game and for efficient recovery from high-intensity short movements. As expected, it seems that the development of performance, such as strength, power, speed, agility, flexibility, and maximum oxygen uptake, may increase athlete’s conditional performance profile. Characterization and comparison of body composition reveals to be an important monitoring tool of players’ development and energy intakes. Further research is required to understand the relationship between players’ characterization and performance over the rink-hockey game. The analysis of external and internal load of players as well as the analysis of technical and tactical actions should be promoted in order to identify reliable key performance indicators that help researchers and coaches to improve preparedness of players to the demands of the game.The analysis of game patterns, shows a combination of specific game momentums with different outcomes according to the game zone. Their understanding may be crucial to develop new training strategies regarding the improvement of the goalkeeper and field players’ performance. In line with previous comments, further research is required to improve the understanding of game dynamics linking technical and tactical behaviors of players and teams. Regarding injuries, the intense short-term movements, collision, and contact between players, in addition to the weight and speed of the hard ball and the stick, can considerably increase the risk of moderate and severe injuries. Finally, there is a need for more research at elite levels regarding patterns of conditional profiles and physiological adaptation while, at the same time, understanding how demanding a top-level competition game can be. Therefore, we believe that it is important to understand what external load challenges the rink hockey athletes are subject to, aiming for the improvement of the training environment. Finally, only English articles searched in Scopus, Web of Knowledge, and PubMed were included in this study. Therefore, the lack of potentially relevant articles in other languages may be a limitation per se. Future steps should allow to focus the inclusion criteria in specific research topic. Additionally, we believe that the lack of international publications regarding the major topics reviewed in this paper may influence the actual reality of sport performance in rink-hockey. Therefore, there is a need to clarify the elite athletes’ traits and game demands in order to develop new evaluation and monitoring tools, which will improve rink-hockey training environments.


The prevention or early treatment of pathological scars is the most appropriate therapeutic approach. Gels and patches containing onion extract and allantoin are safe and effective in patients with scars of various origins and severity. However, no controlled studies have evaluated the effects of the patch formulation in women after Cesarean delivery. This study aimed to investigate the effects of a patch containing Allium cepa and allantoin on Cesarean section (C-section) scars.This is an observational study. Women were consecutively recruited at the University Hospital of Salerno and subdivided into two groups considering the number of C-section. Group A included subjects without and group B with a history of C-section. Scars assessment was made using digital photographs and the Patient and Observer Scar Assessment Scale (POSAS). After 4 weeks, the C-section of the women who had applied a patch containing Allium cepa and allantoin and those of women who had not used any products (controls) were re-evaluated as at baseline. The Observers independently performed the scars assessment at baseline and after 4 weeks. Data are expressed as the difference of the POSAS scores after 4 weeks minus the POSAS scores at baseline. The statistical significance was established at a p value <0.05.Ninety-three subjects completed the study (47 in group A and 46 in group B). Women who had used a patch showed an improvement in total score by observer scale when compared with controls (p = 0.013). By the patient scale, no significant changes from baseline were found in group A and group B. Group B with patch showed changes in scars’ pigmentation (p = 0.015), relief (p = 0.039), and pliability (p = 0.046) in comparison of controls. Digital photographs confirmed such improvements in women who had already undergone previous C-section, while no significant changes from baseline were found in women without a history of C-section.Intense treatment of just 4 weeks with a patch containing Alium Cepa extract and allantoin was able to improve pigmentation, relief, and pliability of C-section scars in women with a history of C-section.ClinicalTrials.gov, identifier NCT04046783. Wound healing is a dynamic process that occurs in response to trauma, burns or surgical procedures, such as Caesarean section (C-section). It is a very complex process encompassing 4 phases: hemostasis, inflammation, proliferation and remodeling. Several molecules, such as growth factors, cytokines, and agents mediating neo-angiogenesis concur all together to repair the wound, restore skin structure and function and re-establish the underlying circulation .Wound healing inevitably leads to skin scarring, which in turn may cause hypertrophic scars and keloids. The latter represent the most complicated scars because they are unlikely to regress over time .A detailed assessment of the scar  is the essential step for choosing the most appropriate therapeutic strategy .Several scales are available to evaluate the appearance and potential symptomatology of the scars both from clinicians and patients’ perspectives. One of them is the Patient and Observer Scar Assessment Scale (POSAS) .Preventing pathological scars and keloids is more appropriate than treating them because the therapeutic options are often invasive and however not resolutive. Surgical excision, often followed by injection of steroids and occlusive action operated by sheeting or bandages, is the most used treatment in the case of pathological scars. Notably, the recurrence rate after surgery is high, ranging from 40 to 100%, and strongly dependent on the original scar localization  and severity .There are several non-invasive remedies useful to both prevention and treatment of pathological scars. Some topical treatments contain natural extracts such as green tea, Aloe vera, vitamin E and D, and onion (Allium cepa) extract useful in contrasting some diseases  and impaAntioxidant, anti-inflammatory, antimicrobial and anti-proliferative activities of the onion extract and moisturizing, anti-inflammatory, and immune-modulatory properties of the allantoin favor a dermo-protective and dermo-repairing action .Then, the same ingredients in the gel have been used in a patch formulation combining the effect of these natural products with an occlusive action on the scar . Many stThe patch formulation combines dermo-restructuring properties of the natural agents and compressive action. It now is commonly used as it is easy to apply encountering the patients’ compliance.Recently, effectiveness and tolerability of such a device have been examined on post-dermatological surgery scars showing positive effects of such a treatment in promoting scar healing , while iTherefore, the present study aimed to evaluate the efficacy and safety of a patch formulation containing Allium cepa extract and allantoin on C-section scars.This is an observational study. Healthy Caucasian women who underwent C-section were consecutively recruited at the University Hospital of Salerno. The inclusion Criteria included: subjects who had undergone Cesarean delivery, age >18, voluntary participation to the study, and informed consent release. The exclusion criteria were represented by age of <18; pre-term birth, obesity, smoking habit, gestational diabetes, hypertension, infections, dermatologic diseases, use of both systemic and topic corticosteroids, and no informed consent release. An identification number was assigned to each subject, and stayed hidden to the observers’ performing the POSAS evaluation.Taking into account the number of C-section, the study population was divided into two groups: group A included subjects without a history of C-section and group B subjects who had already undergone previous C-section.At baseline, after stitches removal, scars assessment was made using digital photographs and the validate Patient and Observer Scar Assessment Scale (POSAS).a posteriori acquisition of data on the patch use by the women was achieved. Because of a posteriori acquisition of the data, the researchers did not provide any instruction to the women that used the patch. The women using the patch reported that had received the suggestion to use the device and the instructions by the cooperating pharmacist in the community. The patch features an occlusive active release liner with an adhesive layer separated by a micro-air cushion seal  were re-evaluated as at baseline. Then, ion seal .Based on the patch use or not, each group was further subdivided in other two groups. At the end, 4 groups were identified: Group A1 including women at the first C-section that did not use the patch, group A2 including women at the first C-section who had applied overnight a patch containing a standardized quantity of Allium cepa extract and allantoin, group B1 including women who have already undergone previous C-section that did not take the patch and who represented the control group, and group B2 including women who have already undergone previous C-section that used the same patch of group A2 Figure 1Verbal and written information was given to the women and their written informed consent was obtained. The local Ethic Committee “Comitato Etico Campania Sud” approved the protocol of the present study (approved number 27_r.p.s.o). The study was registered under the US NIH ClinicalTrials.gov identifier NCT04046783.After stitches removal (at baseline), scars assessment was made using digital photographs and the POSAS (version 2.0). The POSAS consists of two parts: a patient and an observer scale, both including six items the sum of which produces a total score. The patient scale contains six questions to evaluate pain, itching, color, pliability, thickness, and relief; the observer scale analyzes vascularity, pigmentation, pliability, thickness, relief, and surface area of the scar. Since to appreciate the difference between pigmentation and vascularity may be particularly difficult for patients, such characteristics were captured in the item “color” . Each itpost hoc test and are presented as mean ± SD. The χ2 test was used to compare categorical variables. To explore the correlation between variables, Spearman’s correlation (r) was used. The statistical significance was established at a p < 0.05.Data were analyzed using the SPSS (v 23.0) software package . The sample size was calculated from a similar study including women treated with a patch containing Allium cepa extract and allantoin . We usedOne hundred subjects who underwent Cesarean delivery were enrolled and 93/100 women (47 in group A and 46 in group B) completed the study. All were Caucasians with age ranging from 21 to 36 (group A) and 26 to 40 (group B). The characteristics of the study population are reported in The analysis was performed taking into account, for each group, whether a patch containing Allium cepa and allantoin was used or not. This led to a subdivision of the study population into four groups: Group A1 (n = 24) including women at the first C-section that did not use the patch and who represented the control group, group A2 (n = 23) including women at the first C-section who had applied overnight a patch containing a standardized quantity of Allium cepa extract and allantoin, group B1 (n = 22) including women who have undergone previous C-section that did not use the patch and who represented the control group, and group B2 (n = 24) including women who had already undergone previous C-section that used the same patch of group A2.The disposition of women in the study design is shown in At baseline and after 4 weeks, two blinded observers (independent from each other) assessed the scars of the enrolled subjects by using the POSAS. Digital photographs of two subjects for each group are shown in In group A, no differences in POSAS items were found. Conversely, group B showed statistically significant changes in pigmentation (p = 0.015), relief (p = 0.039), and pliability (p = 0.046) between subjects who had used the patch and controls , expressed satisfaction and comfort at the end of the patch use . The patients/participants provided their written informed consent to participate in this study.All authors read and met Frontiers in Pharmacology criteria for authorship. VC, TI, AF, and MG conceived and designed the study. BC, SL, and LG collected the data. GC and VC performed the statistical analysis and interpretation of the data. VC, GC, and TI wrote the paper. AF and MG critically reviewed the manuscript.This work was funded, in part, by a grant to the University of Salerno from Laboratorio Farmacologico Milanese, LFM (300397CPR18LFM). The authors were not directly compensated for completing this research. Beyond providing support for the project, Laboratorio Farmacologico Milanese, LFM did not contribute to the study design, data collection, data analysis/interpretation, writing of the report, or the decision to submit the article for publication. The industry only provided the funds for a possible open access publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Patients undergoing ATSA returned at a higher rate (90%)  compared to RTSA (77%) . Moreover, the results showed that patients returned to sport at the same or a higher level in 75% of cases. Swimming had the highest rate of return (84%), followed by fitness (77%), golf (77%), and tennis (69%). Thus, RTSA and ATSA are effective to guarantee a significative rate of return to sport in elderly patients. A slightly higher rate was found for the anatomic implant.The aim of this systematic review and meta-analysis was to evaluate the rate of return to sport in elderly patients who underwent anatomic (ATSA) and reverse (RTSA) total shoulder arthroplasty, to assess postoperative pain and functional outcomes and to give an overview of postoperative rehabilitation protocols. A systematic search in Pubmed-Medline, Cochrane Library, and Google Scholar was carried out to identify eligible randomized clinical trials, observational studies, or case series that evaluated the rate of return to sport after RTSA or ATSA. Six retrospective studies, five case series, and one prospective cohort study were included in this review. The overall rate of return to sport was 82% (95% CI 0.76–0.88,  Total shoulder arthroplasty (TSA) is the third most common replacement procedure after hip and knee arthroplasty and is considered the elective treatment for patients affected by advanced shoulder pathology with loss of function and severe pain . Indeed,Three main different designs of shoulder prostheses allow surgeons to decide which is the best option for each specific case, trying also to meet patients’ health needs . The revThe constant increase of TSAs, in younger as well as older individuals, correlates with their good long-term outcomes and with the widening of surgical indications ,2. In thThe TSA post-operative rehabilitation protocol plays an important role in active patients to achieve satisfactory post-operative clinical outcomes and range of motion (ROM) . DespiteThe primary aim of this systematic review and meta-analysis is to evaluate the rate of return to sport in elderly patients after ATSA and RTSA. The secondary and tertiary endpoints focus on the assessment of postoperative pain and functional outcomes and to give an overview of current postoperative rehabilitation protocols.The present systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines . In thisAccording to the Oxford Centre of Evidence-Based Medicine, peer-reviewed studies of I to IV levels of evidence were considered for inclusion. Case reports, studies on animals, biomechanical reports, technical notes, letters to editors, instructional courses, cadaver or in vitro investigations, systematic reviews and meta-analyses, or studies without an abstract were excluded. According to the definition of the elderly by the WHO, the search was focused on papers reporting on return to sports of cohorts, with an average age greater than 65 years who underwent RTSA and ATSA. Only studies with a minimum of 10 patients and a minimum of one-year follow-up were included. Moreover, only articles in Italian, English, Spanish, and French were considered.The primary outcome of the analysis was to establish the rate of return to sport of elderly patients after ATSA and RTSA. Among the included papers, the secondary endpoint was to assess the postoperative pain and functional outcomes, taking into account the reported standardized clinical scores. The tertiary endpoint of this systematic review was to give an overview of the proposed rehabilitation protocols.A systematic literature search in Pubmed-Medline, the Cochrane Library and Google Scholar databases was carried out between September 2019 and April 2020. For Pubmed, the following search strategy was used: (((“Shoulder Joint”[Mesh] OR (“shoulder”[All Fields] AND “joint”[All Fields]) AND (“Arthroplasty”[Mesh] OR (“Arthroplasty”[All Fields]) OR (“Replacement”[All Fields])) AND (“Sports”[Mesh] OR (“return to sport” [All Fields] OR (“return” [All Fields] AND (“sport” [All Fields])) AND “Aged”[Mesh])). No time interval was set for publication date. Two independent reviewers (M.C. and C.D.A.) conducted the electronic search identifying the potentially relevant studies. Firstly, the retrieved articles were screened by title and, if relevant, by reading the abstract. After the exclusion of non-eligible studies, the full-text of the remaining articles was evaluated for eligibility. To minimize the risk of bias, the authors reviewed and discussed all the selected articles, the references, as well as the articles excluded from the study. If any disagreement between the reviewers was found, the senior investigator (R.P.) made the final decision. At the end of the process, further potentially missed studies were manually searched for among the reference lists of the included papers and the relevant systematic reviews.All reviewers discussed the relevant items for data extraction before starting the process in order to avoid data omission. Data were independently extracted by two reviewers (M.C. and C.D.A.) and divergences were discussed with the third reviewer (R.P.) if necessary. All data related to primary, secondary and tertiary outcomes were summarized in standardized tables. Specifically, the following variables were recorded: authors, year of publication, type of study, level of evidence, number of participants, mean age, dominant or not-dominant limb, surgical approach, mean follow-up, complications, patients returned to sport and type of activity, secondary outcome measures, and rehabilitative protocols. Among the outcomes, we analyzed functional outcomes and severity of pain.The quality of the included studies was independently evaluated by two reviewers (C.D.A. and M.C.) using the Methodological Index for Non-randomized Studies (MINORS) score . The fol2 test under the null hypothesis that the between-study variance (τ2) equals 0, and I2 test. All the conducted meta-analyses evidenced the presence of significant heterogeneity, defined as a I2 > 55% and a Q statistic p value below 0.05. Accordingly, random effect models were applied. Finally, the likelihood of publication bias was estimated with a visual inspection of the funnel plot. All analyses were carried out using metaphor and meta-packages in R 3.6.1 software for Mac .Meta-analysis was performed to determine the overall proportion of subjects returning to sport and the functional and pain level after shoulder arthroplasty across all the retrieved studies. Raw, i.e., untransformed, proportions and means were used to report the pooled proportions and means that were obtained with the inverse variance method. Heterogeneity was evaluated using Q statistic, expressed as the p value for the χn = 1), German language (n = 1), return to sport not clearly stated (n = 4), and insufficient outcomes data (n = 2). One paper was added from hand search. At the end of the selection process, 11 studies were included in this systematic review and 11 papers were included in the meta-analysis [The initial database searches identified 235 potentially eligible papers. After reviewing title and abstract, 217 papers were excluded and 18 were selected for full-text evaluation. Out of these, eight papers were excluded for the following reasons: mean age of the cohort < 65 years  of level of evidence (LOE) III , four weIn total, 375 ATSA and 750 RTSA were implanted. The side of surgery was specified in 9 studies ,22,23,25The MINORS score ranged from 7 ,25 to 11p < 0.01) (p < 0.01) compared to RTSA (77%)  (p < 0.01)  . Patient < 0.01) . The tim < 0.01) . Six out < 0.01) . Regardi < 0.01) . The detp < 0.01) and 0.8  points respectively  can safely return to at least one sport, with many returning to the same level of play, although a 100% guarantee should not be provided. Bulhoff et al.  assessedThe postoperative rehabilitation protocol was reported in five studies ,22,23,25This systematic review has a few limitations including the number of studies and their heterogeneous methodological approach. Moreover, designs and implantation techniques may have varied significantly across the analyzed studies, thus reflecting the sparse available evidence on the subject and the absence of randomized controlled trials. Importantly, none of these studies mentions the abilities and experience of the surgeon. Since ATSA involves greater operative time and attention, surgical experience could be a determining factor in the decision to perform a reverse or anatomic total shoulder arthroplasty. In order to create a more homogenous cohort, future studies should account for these individual surgeon factors in the methodology. Moreover, all the included studies were affected by a high risk of bias and, in some of them, the follow-up period was quite short to detect important postoperative complications after return to sport, such as loosening or periprosthetic fractures. Patients and sports were heterogeneous as well as the postoperative rehabilitation protocol assessed. Great variability was observed in the postoperative treatment protocols following shoulder arthroplasty. Therefore, it is very difficult to identify common patterns, making it impossible to do a metanalysis of postoperative rehabilitation protocols. Moreover, we performed the metanalysis only on postoperative ASES and VAS scores since their preoperative data were not reported in the included studies, hindering the assessment of significant improvements of these postoperative outcomes. Finally, important postoperative clinical outcomes, such as postoperative ROM, were often not reported.After ATSA and RTSA, elderly patients can satisfactorily resume their sports activities. The rate of return to sports following ATSA is slightly higher than RTSA, probably due to differences in the patient population, surgical indication, and biomechanical issues. Most patients are able to return to practice sport at the same or a higher preoperative level. The most practiced sports after surgery are low contact activities such as fitness, swimming, golf, and tennis. Unfortunately, there is a lack of research data on the advantages and disadvantages of existing rehabilitation protocols and no standard of practice could be deduced. Therefore, more prospective randomized studies are needed to establish which kind of postoperative protocol is best following ATSA and RTSA.


To understand the relationship between nativity and measures of kidney function including estimated glomerular filtration rate (eGFR) and albumin-to-creatinine ratio (ACR).Seven waves of data from the National Health and Nutrition Examination Survey (2001 – 2014) was analyzed. General linear regression methods were used to assess the relationship between eGFR, ACR and nativity (foreign-born vs US-born). Models were adjusted for length of time in the US, demographic variables, comorbidities, lifestyle factors, and access to healthcare.There were 27,111 individuals representing 217,842,257 US adults included in the study. Approximately 26.1% were immigrants, with 40.4% of immigrants having resided <15 years in the US. Among immigrants with <15 years of residence, 51% were Hispanic, and 54.4% had high school or below education. After controlling for demographics and length of time in the US, immigrants were 26% more likely to have an ACR >= 30mg/g ; however, after controlling for demographics, length of time, comorbidities, and lifestyle factors the results were no longer significant. Immigrants were significantly less likely to have an eGFR < 60 , which remained after adjustment .Immigrants had significantly lower odds of having an eGFR < 60 compared to US-born adults. Additionally, immigrants with >= 15 years in the US had mean eGFR values that were less than immigrants < 15 years in the US, indicating that there is some decrease in kidney function as the length of US residence increases. Additioe of CKD . Individe of CKD . The fine of CKD . Early de of CKD , 9.Vulnerable populations including seniors, minorities, and immigrants are at an increased risk of developing chronic diseases, however little is known about immigrants’ risk of CKD , 11. MorDue to being uninsured and limited English proficiency, immigrants are frequently forced to delay and underutilize care needed to manage their chronic disease , 19. It The National Health and Nutrition Examination Survey (NHANES) is a series of cross-sectional surveys that were designed to estimate the health and nutritional status of adults and children in the United States . NHANES Participants were asked “In what country were you born?”, the answers were grouped into born in the US or other country. If the individual answered born outside the US, then participants were asked to indicate the length of time they have resided in the US. Length of time in the US was grouped into < 15 years or >= to 15 years for those who were foreign-born. These cut points were selected based on the literature showing immigrant health declines as length of residence increases, with those who have lived in the US 15 years or longer having six times the odds of experiencing change in health compared to those who have resided in the country less than a year  – 15. ReUrinary albumin and urinary creatinine are measured in a random urine collected in the mobile examination center (MEC). The random urine albumin (URXUMA) in ug/mL and urine creatinine (URXUCR) in mg/dL were converted to the albumin/creatinine ratio (URDACT) in mg/g: URDACT = URXUMA/URXUCR × 100, round to .01. ACR was categorized as <30  or ≥30 (moderate to severe) based on Kidney Disease Improving Global Outcomes (KDIGO) guidelines . EstimatComorbidities included hypertension, major adverse cardiac event (MACE), and depression. Hypertension was defined by the question: “Have you ever been told by a doctor that you had high blood pressure?” MACE was defined by any of the following been told by a doctor that the participant had: stroke, heart attack, angina, coronary heart disease, congestive heart failure. Depression was measured using the Patient Health Questionnaire (PHQ-9), a nine-item screening instrument that asks questions about the frequency of symptoms of depression over the past 2 weeks. Responses were given a point ranging from 0 to 3. Depression was coded as no depression (score 0–9), depression (score 10–27), and unknown (with missing score) .2) and was calculated from physical examined weight and height. BMI was dichotomized as less than 25 or greater than or equal to 25.Smoking was defined by whether the individual smoked at least 100 cigarettes in their lifetime, and was grouped as none, former, or current smoker. Physical activity was based on the individual’s engagement in work and recreational activities and was categorized as vigorous, moderate, and none. Obesity was determined using Body Mass Index(BMI) , race/ethnicity , education (dichotomized as high school or below and college or above), marital status (dichotomized as married or not married), and ratio of family income to poverty (dichotomized as 130% and less of poverty level and above 130% of poverty level).2 and greater than or equal to 60 ml/min/1.73m2, univariate and multivariable survey logistic regression were used to assess the relationship between country of birth and ACR, country of birth and eGFR, controlling for length of time in the US. Last, demographic variables , access to health care, comorbidities, lifestyle factors were added in sequence to multivariable logistic regression to check for their influence. All p-values were 2-sided and p<.05 was considered statistically significant.Data analysis was performed using SAS version 9.4 (SAS Institute). The data are weighted and the SURVEYFREQ, SURVEYMEANS, SURVEYREG, and SURVEYLOGISTIC procedures in SAS were used to represent the U.S. population and account for the complex survey design. The primary analytical goal was to explore the ACR and eGFR between US born and foreign born adults residing in the US. First, the nativity  was compared by demographics using ANOVA. Second, US-born and foreign-born with >= 15 years of residence was compared by demographics using Rao-Scott chi-square statistics to determine whether the healthy immigrant effect hypothesis held. Third, the weighted means for ACR and eGFR were calculated for all the covariates. Fourth, ACR was dichotomized as greater than or equal to 30 mg/g and less than 30 mg/g, eGFR was dichotomized as less than 60 ml/min/1.73mThe population sample included 27,111 adults 20 years and older, representing 217,842,257 US adults 20 years and older. In a population representative of native-born and foreign-born adults in the United States, mean eGFR was high for both foreign-born (101.5) and US-born (92.9), while mean ACR was greater than 30 mg/mmol for both groups indicating possible presence of kidney damage . As seenWhile the unadjusted model comparing US-born to foreign-born for ACR > 30 was not statistically significant, after adjusting for length of residence the relationship became significant and showed that foreign-born individuals had 26% increased likelihood of having ACR > 30. This change in significance indicates that length of residence is an important factor to consider when explaining the relationship between nativity and risk of having an ACR >30. However, when the model was adjusted for length of residence, demographics, and access to care it was found that foreign-born had 15% less likelihood of having ACR >30 when. This shift in direction of association from increased risk to decreased risk indicates that demographic variables and access care are additional key drivers in explaining the relationship between ACR and nativity. Finally, once comorbidities were added to the model, the relationship was no longer significant which suggests that comorbidities may explain why length of residence in the US is an important factor in the relationship between immigration status and ACR.The results showed that mean ACR was > 30 for both foreign-born and US-born individuals which poses an increased risk for all-cause and cardiovascular mortality . EventhoThis study provides previously unknown information about the relationship between foreign-born and US-born status and CKD as assessed by eGFR and ACR. Additional research needs to be done to gain further understanding on immigrant specific factors that may affect CKD development and progression in the foreign-born population residing in the US. It is known that immigrants often face multiple barriers to health care services including linguistic, transportation, financial, and cultural barriers , 28. The2) or evidence of kidney damage lasting three or more months is required. Second, there is possible recall bias due to self-report of variables other than ACR, eGFR, and BMI. Third, because the foreign-born population was slightly younger than the US-born our mean ACR and mean eGFR values may not reflect levels of older, high-risk individuals.Strengths of this study include the large number of foreign-born and US-born individuals representative of adult population in the US, nine years of data, and availability of biological measures for CKD. The study does have a few noteworthy limitations. First, this was a cross-sectional study and causation cannot be determined based on the findings. In addition, we are unable to make a diagnosis of CKD in our study population since a decrease in eGFR (<60 ml/min/1.73mThis study fills an important gap in knowledge on the relationship between country of birth and signs of kidney damage. While foreign-born individuals had higher mean eGFR than US-born, foreign-born had no significant increase in odds of having an ACR greater than or equal to 30 mg/g after adjusting for all covariates. Foreign-born had lower odds of having eGFR less than 60 compared to US-born individuals, however, foreign-born with greater than 15 years in the US had mean values that were lower than those with less than 15 years in the US, and more similar to US-born individuals. Our results indicate there may be some decrease in kidney function as the length of US residence increases, however, more research is needed to gain a greater understanding of the relationship. Based on these results efforts to increase access to screening and awareness of CKD may be warranted for immigrant populations.10903_2020_1054_MOESM1_ESM