Conversion rate from laparoscopic to open surgery was 2.5%. There was a drop in estimated glomerular filtration rate (eGFR) at discharge of 36 mL/min in the LDN and 32 mL/min in the ODN groups, respectively (p = 0.03). No death, readmission or reoperation were recorded. There was a significant difference in favor of LDN group for each one of the eight items of the questionnaire (SF1–SF8). As for the two summary scores, while the total physical component summary (PCS) score was comparable between the two groups (57.87 in the LDN group and 57.07 in the ODN group), the mental component summary (MCS) score was significantly higher  in the LDN group. This study provides evidence that minimally invasive surgery can be performed safely, with very good short-term outcomes, providing several benefits for the living kidney donor, thereby contributing to expanding the living donor pool, which is essential, especially in countries with deceased-donor organ shortage.Since its introduction in 1995, laparoscopic nephrectomy has emerged as the preferred surgical approach for living donor nephrectomy. Given the ubiquity of the surgical procedure and the need for favorable outcomes, as it is an elective operation on otherwise healthy individuals, it is imperative to ensure appropriate preoperative risk stratification and anticipate intraoperative challenges. The aim of the present study was to compare peri-and postoperative outcomes of living kidney donors (LD), who had undergone laparoscopic nephrectomy (LDN), with a control group of those who had undergone open nephrectomy (ODN). Health-related quality of life (QoL) was also assessed using the validated SF-36 questionnaire. Data from 252 LD from a single transplant center from March 2015 to December 2020 were analyzed retrospectively. In total, 117 donors in the LDN and 135 in the ODN groups were assessed. Demographics, type of transplantation, BMI, duration of surgery, length of hospital stay, peri- and postoperative complications, renal function at discharge and QoL were recorded and compared between the two groups using Stata 13.0 software. There was no difference in baseline characteristics, nor in the prevalence of peri-and postoperative complications, with a total complication rate of 16%  in both groups, while a different pattern of surgical complications was noticed between them. Duration of surgery was significantly longer in the ODN group (median 240 min vs. 160 min in LDN,  Kidney transplantation (KTx) undoubtedly offers the best therapeutic option for patients with end stage renal disease (ESRD), resulting in substantial improvement not only in quality of life (QoL) but, most importantly, in life expectancy of the recipient compared to renal replacement therapies (RRT) . CompareEspecially in countries with deceased-donor organ shortage, such as is Greece, expanding the living donor pool is essential, since living KTx comprises almost two-thirds of the total kidney transplant activity of the country.Living kidney donors represent a unique population, posing a great challenge to both transplant surgeons and nephrologists: they are healthy individuals voluntarily undergoing a surgical procedure of organ removal with a purely altruistic motive, where the recipients benefit. Safety of the surgical procedure and excellent short- and long-term results regarding all health-related outcomes of LD are prerequisites of paramount importance.Living kidney donation has proven safety in several studies, with low rates of mostly minor complications and minimal mortality . Since iThe aim of the present study was to investigate perioperative and short-term outcomes of living kidney donors who had undergone laparoscopic nephrectomy (LDN), compared to a control group of patients after open donor nephrectomy (ODN) at our institution.n = 252) from the Renal Transplant Unit of Laiko General Hospital of Athens from March 2015 to December 2020 were analyzed retrospectively. From its introduction in October 2018 in our center, LDN was the standard nephrectomy procedure in all living donors, with very few exceptions, due to logistic reasons. Data from all (n = 117) living donors who had undergone laparoscopic nephrectomy were collected. All consecutive living donors who had undergone open nephrectomy (n = 135) from that time backward until March 2015 served as control group. The study was approved by the local ethics committee.All consecutive living kidney donors  to individually assess the functional status of each kidney. If both kidneys were suitable for transplantation, for all donor nephrectomies (whether open or laparoscopic), if there was a single artery, our practice was to prefer the left kidney. If there were two renal arteries or more on the left kidney and a single artery on the right kidney, we would take the right one. If there were multiple arteries bilaterally, we removed the left kidney. If there was an incidental minor abnormality , we removed the kidney with the abnormality, leaving the living donor with the normal kidney.Data collected on living donors included transplantation characteristics, i.e., preemptive or ABO-incompatible transplantation; donor and recipients demographics; donors’ comorbidities and BMI; duration of operation; warm ischemic time (WIT); length of hospital stay; any intra- and postoperative complications, according to the Clavien–Dindo  classifiFurthermore, health-related quality of life (HRQL) was assessed using the standardized SF-36 questionnaire in both donor groups. The Short Form-36  questionnaire is a generic measure of perceived health status. The SF-36 includes 36 items, which can be aggregated into eight scales: physical functioning (PF), physical role (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), emotional role (RE) and mental health (MH). These eight scales yield two summary measures: physical component summary score (PCS) and mental component summary score (MCS) . We compContinuous variables were expressed as mean and standard deviation, and categorical variables as frequency and percentage (%). To investigate the differences between clinical variables in patients who underwent open or laparoscopic nephrectomy, the t-test and Mann–Whitney U test for independent samples for continuous variables and the chi-square test for categorical variables were applied. Data were analyzed using Stata 13.0 software . Significance was set at α = 0.05, and all tests proceeded as two-tailed.As for the SF-36 questionnaires, a scoring algorithm, recommended by the developers, codes, sums and transforms the responses per domain into a scale from 0 to 100, with higher scores indicating better health status. Specifically, after the data entry, the item recoding procedure takes place by changing out-of-range values to missing. Subsequently, recoding values for 10 items is conducted to ensure that a high score indicates better health status and to satisfy the equal interval assumption, and missing item responses are recoded with mean substitution when the respondent has answered at least half of the items in a multi-item scale. Finally, raw scale scores are computed and transformed to a 0–100 scale .Additionally, summary components are computed through a standardized three-step process that adds together the scores from all domains with differing weightings, based on the principal component analysis method. First, the eight dimensions are standardized using a z-score transformation; second, z-scores are multiplied with the respective factor score coefficient and summed in order to compute aggregate scores; and finally, the obtained scores are standardized using a T-score transformation (mean 50 and SD 10) . The SF-All surgical procedures were performed in the Renal Transplant Unit of “LAIKO” General Hospital of Athens. All eligible donors who were considered for kidney donation were informed about the surgical approach. Standard preoperative screening of donors included examination by a nephrologist, a transplant surgeon and an anesthetist. Three transplant surgeons performed all the surgical procedures in both donor groups, whereas only one performed all LDN. Regarding the selection of the surgical procedure of the kidney living donors, surgeon experience and donor factors, such as BMI and kidney anatomy, were taken into account. During the period prior to October 2018, the ODN was the only one surgical option that our center has offered. This kind of donor nephrectomy was carried out by three different surgeons with appropriate experience; two of them had no experience with laparoscopic donor nephrectomies. Since October 2018, a well-codified minimally invasive LDN surgical program has been established; this was followed by standardization of the surgical procedure and development of a well-defined surgical team, including a surgeon highly skilled in laparoscopic and robotic surgery and transplantation surgery, who was previously trained in other transplant centers and who has performed all LDNs.(1) LDN2O carbon dioxide pressure. A 30° video endoscope was introduced. Three to four trocars were introduced in the peritoneal cavity under direct vision. The colon was mobilized and displaced medially. After opening the Gerota’s fascia and division of the perirenal fat, the ureter and vascular structures were dissected. A 5–7 cm Pfannenstiel (suprapubic transverse) incision was made as extraction site. The ureter was clipped and divided, and the renal vessels were stapled. The kidney was recovered with an endobag  ODN (Flank incision)With the donor placed in a lateral decubitus position, lumbotomy was performed with a horizontal 20–30 cm skin incision anterior to the 11th rib. A mechanical retractor was used. The muscles of the abdominal wall were split. Gerota’s fascia were opened on the lateral side of the kidney. After dissection of the kidney and its structures, the ureter, renal artery and vein were subsequently divided, and the kidney was extracted. The fascias of the abdominal muscles were closed, and the skin was clipped or sutured intracutaneously .Preperitoneal placement of the renal graft in the iliac fossa was applied as the standard operation technique.For this study, the following data were collected: age, sex, BMI, relation to recipient, operative time (OT), side of operation, perioperative bleeding, prior abdominal surgery, number of renal arteries, other anatomical variants, warm ischemic time (WIT), intraoperative complications, conversion to open surgery, reason for conversion, postoperative complications and length of hospital stay. The OT was from skin to skin. WIT was recorded and documented in the operating theater by a coordinator or nursing staff. The time recorded was from when the artery was clamped and stapled until the kidney was immersed in ice sludge on the back table and flushing of the artery with cold perfusion solution began. Postoperative hospital stay is from the first postoperative day until discharge.2 and mean preoperative estimated glomerular filtration rate (eGFR) of 93 and 96 mL/min, respectively. Left kidney procurement was the preferred surgical approach: the left kidney was removed in 87.4% of donors in the ODN group and in 86.3% in the LDN group. The only significant difference between the two groups was the frequency of past abdominal surgery: a substantially higher proportion of donors in the LDNgroup (39%) had undergone abdominal surgery prior to nephrectomy, compared to 18.2% in the ODN group (p < 0.001).Transplantation and donor characteristics in both ODN and LDN groups are listed in Age distribution was similar between groups. As shown in 2) were more prevalent  in the LDN group.Mean donor BMI did not differ between groups. However, obese donors (BMI > 30 kg/mPreemptive kidney transplantation (KTx) was performed in 18.5% of cases in the ODN group and in 13.5% in the LDN group and ABO-incompatible KTx in 7.4% and 29%, respectively.p =0.03).Comparison of major outcomes between groups is depicted in Intraoperative parameters by surgical technique are reported in p < 0.01).The duration of surgery (operative time in min) was counted from skin to skin. In our study, ODN required an operative time that was, on average, 80 min longer than LDN (p < 0.01).LDN was associated with significantly longer warm ischemic time (WIT)  and is reported in The 12 intraoperative complications regarding the LDN cohort were CDC II in severity and required no surgical or other intervention .The conversion to open rate within the LDN group was 2.56% . Of note, there were no intraoperative or immediately postoperative living donor deaths in our study.Postoperative outcomes for our cohort are listed in p < 0.01)).LDN was associated with a significant reduction in the average length of hospital stay . In addition, the severity of complications between the examined groups was comparable  and are reported in Of interest, no readmissions have been documented in both access groups.The median SF-36 scores in both groups are presented in p < 0.001) in the LN group. Of note, donors with laparoscopic nephrectomy had undergone surgery more recently than controls: time since nephrectomy in this group was 11 ± 7 months, compared to 42 ± 13 months in the control group of donors with open nephrectomy.There was a significant difference in favor of the LDN group for each one of the eight items of the questionnaire (SF1–SF8). As for the two summary scores, while the total physical component summary (PCS) score was comparable between the two groups (57.87 in the LDN group and 57.07 in the ODN group), the mental component summary (MCS) score was significantly higher  technique. The rationale for this choice was based on morbidity issues and concerns with ODN, which represents a major surgical trauma that causes postoperative pain, discomfort, and more long-term complications to healthy volunteers who have no direct therapeutic benefit of the procedure ,6. SinceLDN is a difficult procedure that requires extensive experience in minimally invasive laparoscopy and is surely a more demanding and challenging procedure than ODN. Exact effects, risks and limitations of learning curves in LDN are difficult to estimate. Descriptions vary, from 20% major complications during the first 50 cases and 6% during cases 200–250 to 30% major complications during the first 30 LDN cases with no complications during the following 50 cases ,22,23. IIn our experience, we observed a relevant procedure-related learning curve, and some of our complications and results  might have been related to such a learning curve. Regarding the selection of the donor nephrectomy surgical procedure, surgeon experience and donor factors, such as BMI and kidney anatomy, were taken into account. In general, ODN was the only option offered during the period prior to October 2018. On the other hand, LDN was the first option used at our institution since October 2018. In the early phase of the learning curve in cases with BMI >30, ODN was considered. In our experience, taking into account surgeons’ prior training and experience in advanced laparoscopic and robotic-assisted procedures, it was relatively safe to develop and implement a new minimally invasive program for LDN, while, according to our results, we estimate the mean number of consecutive cases necessary to reach proficiency in LDN to be between 15–20.The two groups had similar baseline characteristics. Almost two-thirds of donors in both groups were over 60 years old. Remarkably, obesity, which poses technical difficulties, was more prevalent in the LDN group.As safety of the donor is the primary consideration in living donor surgery, all major peri- and postoperative outcomes were thoroughly investigated and compared between the two groups.Perioperative mortality rate, though existing, is minimal and has been reported at 0.03 % . In our In a recent European Update survey, the median conversion rate was 2% . The median case volume in centers that converted one or more procedures was significantly higher than centers that did not ,27.Our sp < 0.008), there was no difference in complication rates. As obesity becomes increasingly common, more potential kidney donors are likely to be obese as defined by BMI, with 63.6% of donors classified as overweight or obese in a review of 2015 [Obesity has been associated with an increased risk for perioperative complications. Notably, in our cohort, though obesity was more prevalent in the LN group . Of interest, we combined other surgical procedures like cholecystectomy, umbilical hernia repair and incisional hernia repair in six cases, even in donors with previous major abdominal surgeries.Virtually all donors eligible for an open surgical procedure may also undergo the laparoscopic operation. Various earlier contraindications to LDN, such as right donor kidney, multiple vessels, anomalous vasculature and obesity have been overcome with increasing experience ,24,25,27p < 0.01). The reason for this finding is that, during the most of the ODN cases, the surgeon was waiting for the recipient, who was operated on simultaneously, to be prepared for transplantation in order to remove the kidney graft, having a pause of at least 60 min.In most reported experiences, the operating time at the beginning of the LDN learning curve was generally longer than for ODN. In a meta-analysis of published reports regarding the current status of LDN, the operating time was significantly longer in LDN series compared with open donor nephrectomy series . HoweverLDN and ODN are comparable in the estimated blood loss and postoperative transfusion requirement ,18. In fp < 0.01). This fact seems to be associated with some problems in the use of the extraction endobag and the dissection of the kidney upper pole, especially in obese donors, during the beginning of the learning curve, which required prolonged extraction time.WIT represents a major concern, as it has always been slightly longer in the laparoscopic group when compared with ODN, due to the longer extraction time. It has been thought that any increase in this would translate into a poor graft function. This notion has been disproved by various studies, suggesting no bearing of this small difference on the recipient outcome ,25,27. IThe WIT can be reduced with increasing experience, as shown in different studies ,23,35. PWe evaluated the impact of warm ischemia time in LDN. It correlated with the incidence of delayed graft function. In two patients, where it took 25 min and 15 min to retrieve the renal grafts, both the kidneys worked well and had diuresis in the immediate postoperative period.p < 0.03). Though marginal, the difference was in favor of the ON group. The reported decline in eGFR in both our donor groups is in the expected range, since, at 6 weeks postdonation, the reported declineis 33%in young donors (18–30 years old) and 35–37% in older donors. After that, an average increase in eGFR +0.35 mL/min annually, is expected [In our current study, we noted minor but statistically significant differences in the creatinine level and eGFR at discharge between the LDN and ODN cohorts at baseline. Regarding renal function, there was a drop in eGFR from 93 to 60 mL/min in the ON and from 95.5 to 59 mL/min in the LN group, which corresponds to a ΔeGFR of 36 and 32 mL/min, respectively (expected .p < 0.01)) which, except for faster recovery, is particularly important for the safety of the donors, especially in the times of the COVID-19 pandemic.LDN has been demonstrated to reduce the postoperative analgesic requirement, hospital stay and the length of convalescence, as compared to ODN . Comparip< 0.05). Similar to the experience of others, we observed remarkably higher incidence of postsurgical pain in ODN, which could be explained by the refinement in surgical techniques with less intraoperative nerve injury in the LDN. In accordance, ODN is a more invasive procedure compared to LDN, because of the use of a muscle-splitting flank incision instead of an intermuscular Pfannenstiel incision [Reduced postoperative pain and recuperative time, the major advantages of LDN, have been demonstrated in several studies ,16,22. Rincision .Several series have addressed donor quality of life following LDN and ODN. It has been shown that LDN resulted in a shorter time until patients were able to return to normal physical activity and work ,25.As health-related QoL is a major concern in living kidney donors, several studies have investigated this issue using standardized quality of life scales, including the SF-36 questionnaire. Most studies have reported excellent outcomes in LDs, with LDs scoring even better in many items of the questionnaire, compared to the general population, which can be explained by psychological benefits, such as enhanced self-esteem as a result of donation ,38,39,40In our study, all donors in both groups scored highly in each one of the separate eight items of the SF-36 questionnaire . There wDonors in the LN group had shorter time from donation until completion of the survey. However, time since donation does not seem to influence the SF-36 scores ,40,45. TLong-term follow-up data, especially for “extended criteria” or “complex” living donors  are lacking, as these donors have been increasingly accepted, mainly during the last decade. It has been shown that donors with overweight/obesity and donors with vascular multiplicity have good short-term results .Previous studies demonstrated that older living donors have excellent outcomes . More thLDN minimizes the drawbacks of ODN and makes the prospects of live donor nephrectomy more appealing to prospective donors by reducing postoperative pain, shortening convalescence and improving the cosmetic outcome of donor nephrectomy. LDN has shown the potential to increase the number of living kidney donations by removing some of the disincentives inherent to kidney donation itself ,24,47. ITo enlarge the donor pool, the use of living donors in Europe has increased. Many centers have, therefore, placed greater emphasis on living kidney donation to meet the growing demand for kidney transplantation in patients with ESRD ,47,49.Our transplant center moved toward the same direction. It is the biggest in Greece, with the most organized living donor program. We strongly believe that the initiation of the LDN in our center, which is the only one at the moment in the country that regularly performs minimally invasive donor nephrectomies , has given impetus to the expanding of our live donor kidney transplant program. Over the past three years we have performed 181 renal transplantations from LDs, with 48 of them having been performed in 2018, 58 in 2019 and, of interest, 75 in 2020, despite having temporarily (2.5 months) paused the program during the first wave of the COVID-19 pandemic. This accounts for the 75, 80 and 88% of the total annual transplant activity of the country, respectively .It is evident that the annual number of available organs from deceased donors will not resolve the organ shortage. Living donors have thus emerged as an even more important donor category. The superior outcomes of living donor kidney transplantation, the increased willingness of living donors to help their loved ones and the recent advances in LDN have, to some degree, helped to meet the increasing need for kidney allografts. The price we certainly pay is a growing dependency on healthy individuals who undergo a major surgical procedure with no direct therapeutic benefit.At the transplantation unit in “LAIKO” General Hospital of Athens, the annual number of living donor kidney transplantations increased from 20 to almost 75 within a 5-year period, while the number of deceased donor transplantations remains constantly low. Today, living donation around the world has increasingly become the treatment of choice for patients with ESRD. Transplant centers should demonstrate sufficient volume of surgical procedures and training  to ensure a high level of surgical skills and state-of-the art care of the living donor.In view of the increasing kidney demand, the transplant community should continuously reevaluate the accepted exclusion criteria for donors. In the future, more “complex” living donors will have to be accepted. From our study, it is obvious that even those donors may safely donate with very good results.


With accelerated urbanization in China, an increasing number of the migrant elderly following children (MEFC) have appeared. This study aims to explore the effects of living conditions, subjective integration, and social networks on the health-related quality of life (HRQOL) of MEFC in Jinan, China. HRQOL was assessed by the 12-item Short-Form Health Survey, which included the mental component summary (MCS) and the physical component summary (PCS). Univariate analyses and binary logistic regression were used to investigate the association between the above indicators and HRQOL. A total of 656 MEFC were selected by multi-stage cluster random sampling, 25.2% and 25.0% of whom were defined as poor MCS and poor PCS, respectively. Those who understood the local dialect, could trust others, and connected with friends were more likely to have good MCS; those with a nanny, faulty elevator, and no support from their spouse were the reverse. MEFC who were trans-city, had no elevator or a faulty elevator, and went to the hospital alone were more likely to have poor PCS; those who approved of living conditions in their hometowns were the reverse. Results indicated that better living conditions, stronger subjective integration, and wider social networks led to higher HRQOL of MEFC. Implications of the government, communities, and families of MEFC were given to improve their HRQOL. Over the past decades, with the rapid development of China’s economy and the general improvement in medical technology, the process of aging and urbanization has gradually intensified, and the scale of population mobility has been constantly expanding . From 19Health-related quality of life (HRQOL) is defined as an individual’s satisfaction or happiness with the quality of their physical and mental health and is deemed a comprehensive assessment tool of a population’s health status . It was Previous research clarified that living conditions were determinants of health . A populSocial integration has been proven to be one of the most important issues affecting the physical and mental health of the migrant elderly . It is aSocial networks could be described as social units  or the sGiven the above background, there is no study that simultaneously explores the effects of living conditions, subjective integration, and social networks on HRQOL, let alone takes MEFC as the research object. Thus, this study aims to explore the effects of living conditions, subjective integration, and social networks on HRQOL of MEFC in Jinan, China.The data were collected in Jinan City, Shandong Province, China, in August 2020. Shandong Province lies in the east of China, and Jinan City is the capital city of Shandong Province. Its Gross Domestic Product (GDP) in 2020 was 1.01 trillion Chinese Yuan  . As of 1In the first stage of the data collection, three districts were chosen from the 10 districts as the primary sampling units (PSUs), considering their economic development and geographic location. In the second stage, a total of three sub-districts were selected from each of the PSUs as the secondary sampling units (SSUs). In the third stage, three communities were selected from each of the SSUs. All the migrants who were older than 60 years and followed their children to Jinan in these three communities constituted the total sample of this study.In total, 32 university students became investigators for this study after receiving training regarding the background information of the study, contents of the questionnaire, and techniques of social survey. The investigators conducted approximately twenty-minute face-to-face interviews with the subjects to collect the data. A total of 670 MEFC were initially selected and interviewed. However, 14 of them were excluded due to obvious logical errors in their responses or uncompleted questionnaires. A total of 656 participants were ultimately included in the study.The Short-Form Health Survey (SF-12), consisting of 12 items drawn from the eight subscales of the SF-36 , is wideSocial demographic characteristics, which were collected as a basis for comparison, included age, gender, marital status, education, duration in inflow area, hiring a nanny, and migration space range.Living conditions were captured by three indicators, including two objective indicators of current residence, “type of housing” and “elevator faults”, and one subjective evaluation of “living conditions in hometown.”Subjective integration was mainly measured through the dimensions of acculturation and self-identity. Factors including “local dialect” and “trust others around you” were used to measure the dimension of acculturation. Self-identity was measured by the question “Do you feel like a local?”Social networks in this study were measured through two dimensions: family relationships and social relationships. Participants’ family relationships were measured by their responses to four questions: “Do you have different consumption values from your children?” “Do your children work overtime at home because of their busy schedule?” “Have you gone to the hospital without children’s company for fear of troubling them?” “Do you have support from your spouse?” Social relationships were measured by two indicators: “number of local friends” and “relationships with friends and colleagues.”p-values less than 0.05 were regarded as statistically significant. Chi-square test was used to calculate the differences in MCS and PCS among the subgroups of each categorical variable. After univariate analyses, statistically significant variables were included in the logistic regression analyses. Three binary logistic regression models with an enter method were adopted to explore the associations between independent variables and HRQOL. Meanwhile, crude odds ratios (OR) and 95% confidence intervals (95% CI) were calculated. First, social demographic characteristics and living conditions entered Model 1, then the indicators of subjective integration were brought into Model 2, and finally the variables of social networks were added to Model 3.All statistical analyses were performed using IBM SPSS 24.0, and The basic information of social demographic characteristics, living conditions, subjective integration, and social networks of 656 participants is provided in p < 0.05), type of housing (p < 0.05), elevator faults (p < 0.001), local dialect (p < 0.01), trusting others (p < 0.05), support from their spouse (p < 0.05), and relationships with friends and colleagues (p < 0.05). As for PCS, there were statistically significant differences in age (p < 0.05), migration space range (p < 0.01), type of housing (p < 0.001), elevator faults (p < 0.001), living conditions in their hometowns (p < 0.05), local dialect (p < 0.05), feeling like a local (p < 0.05), different consumption values from children (p < 0.05), children working overtime at home (p < 0.01), going to the hospital alone (p < 0.01), support from their spouse (p < 0.05), number of local friends (p < 0.05), and relationships with friends and colleagues (p < 0.05).As shown in p-values, OR, and 95% CI for the association of the significant variables after univariate analyses with MCS and PCS, respectively. The collinearity diagnostics’ results revealed that the tolerances of all independent variables were much greater than 0.1, and the variance inflation factors were far less than 10, suggesting that there was no multicollinearity between independent variables in three logistic regression models.p-value (p = 0.449) was greater than 0.05 and the percentage accuracy in classification was 75.8%, indicating a high prediction effect. Model 3 presented that living conditions, subjective integration, and social networks were statistically associated with MCS. Specifically, MEFC who often had elevator faults , were able to understand or speak local dialect , could trust others , and kept frequent contact with friends and colleagues  were more likely to have good MCS, but for those who hired a nanny , sometimes had elevator faults , and had no support from their spouse , the scores were reversed.In p-value greater than 0.05 in the Hosmer and Lemeshow test and 81.7% accuracy in classification, the results of Model 3 indicated that migration space range, living conditions, and social networks were significantly associated with PCS. Specifically, the elderly who were trans-city migrants , had no elevator in their houses  or sometimes had elevator faults , and had sometimes  or often  gone to the hospital alone were more likely to suffer from poor PCS, and those who gave a good  or fair  evaluation of living conditions in their hometowns were more likely to have good PCS.As shown in In this study, the mean scores of MCS and PCS were 55.44 ± 7.10 and 48.51 ± 9.59, respectively. Compared with community-dwelling elderly in Zhejiang, China .The present study demonstrated that living conditions were associated with HRQOL of MEFC. Some studies have suggested that recreational amenities , home amThis study demonstrated that the impact of subjective integration on HRQOL of MEFC was greater on the mental aspect (MCS) through the dimension of acculturation, compared with the physical aspect (PCS). Language barriers have always been one of the most difficult issues affecting the normal work and life of migrants in the inflow area ,57,58. MSocial networks have been found to be associated with HRQOL. Having support from spouses and close relationships with friends and colleagues demonstrated significant differences in MCS. According to other studies, spouses may be able to provide stability and emotional comfort for the migrant elderly  and may In terms of demographic characteristics, the significant predictors of HRQOL were hiring a nanny at home and migration space range. Hiring a nanny was a risk factor for MCS of MEFC, probably because the elderly and nannies had different views on taking care of their grandchildren. Nannies usually receive professional training and adopt more scientific methods, while the elderly tend to follow their traditional experiences . RegardiTo improve the HRQOL of MEFC, the government may take the following measures. First, on the basis of protecting the diversity of traditional culture, continue to promote the popularization of Mandarin to alleviate the obstacles of dialect among the elderly, vigorously promote the construction of an elderly-friendly city, and reinforce the safety of public facilities so that the elderly can live in a safe and convenient social environment. Second, as the central living space of MEFC, the community plays an important role in improving their HRQOL and is supposed to conduct more recreational activities, so as to increase opportunities for MEFC to build close friendships and trust with the local residents. Meanwhile, it is an essential responsibility of the community to maintain the security of its infrastructure. Last but not least, the children of MEFC should accompany and be filial toward their parents in order to create a happy family atmosphere.There are several limitations to this study. First, we used data from a cross-sectional study, so the causal relationship could not be predicted. Second, due to the lack of a systematic scale on living conditions, subjective integration, and social networks in the questionnaire, we only selected some relevant indicators to conduct our evaluation, which was expected to be remedied in the follow-up study. Finally, affected by COVID-19, our study failed to conduct the survey in Shanghai as planned and only selected MEFC in Jinan as the research object, which might not represent HRQOL of MEFC in China.In summary, to the best of our knowledge, this was the first study to explore the determinants of HRQOL among Chinese MEFC from the perspective of living conditions, subjective integration, and social networks. The results indicated that the better the living conditions, the stronger the subjective integration, and the wider the social networks, the higher the HRQOL of MEFC. Understanding the local dialect, trusting others, and maintaining contact with friends positively impacted MCS, but hiring a nanny, sometimes having elevator faults, and having no support from their spouse impacted MCS negatively. Trans-city migration, elevator faults, and going to the hospital alone had negative effects on PCS, and better evaluations of living conditions in their hometowns reversed this effect.


The purpose of this cross-sectional study was to analyse the differences in meaningful activities and psychosomatic function depending on the driving status of community-dwelling older adults. Data from 594 older adults were obtained, including activities meaningful to individuals and psychosomatic functions, such as grip strength, depression, cognitive function, and ability of activity. Participants were divided into active driving (n = 549) and after driving cessation (n = 45) groups. In addition, the active driving group was operationally divided into three groups: high-frequency group (n = 387), medium group (n = 119), and infrequent group (n = 42). In the after driving cessation group, grip strength, and Japan Science and Technology Agency Index of Competence scores were significantly lower. Furthermore, the proportion of apathy and physical and social frailty was significantly higher in the after driving cessation group. Regarding meaningful activity, domestic life scores in the after driving cessation group were significantly higher than those of the active driving group. Decreased driving frequency in the active driving group was associated with weak muscle strength, lack of interest, and low activity. This study demonstrated that meaningful activity differed based on the driving status. Hence, we should support the activities of older adults who are considering driving cessation. In Japan, the number of driver’s license holders aged 75 years and above is increasing, causing many fatal accidents . To resoTarumizu City (Area: 62.49 square miles), with a population of 14,379 and a low population density, is one of the least populated areas of Japan, and its population aging rate is extremely high. In addition, public transportation is inadequate and driving is necessary to perform various essential life functions. Participation in activities is essential for older adults as it benefits their health and improves their psychological well-being and health-related quality of life ,18. In 2This cross-sectional study aimed to analyse the differences in meaningful activity and mental and physical function between community-dwelling older adults with different driving statuses . Understanding how reduced outings and driving affect the physical and mental functioning and activity of older people is useful while considering pre- and post-driving cessation support preparations.This cross-sectional study used data from the Tarumizu Study 2018. It was a collaborative study undertaken by Kagoshima University, the Tarumizu City office, and Tarumizu Chuo Hospital. This study was conducted from June to December 2018 as a community-based health survey. Reply-paid postcards were mailed to the residents of Tarumizu City who were aged 40 years or older at the time of examination, and residents were recruited through local newspaper advertisements and community campaigns. The recruitment period was from April to June 2018, and 1385 people participated in the survey. The survey was conducted at public facilities in Tarumizu, and participants attended one of 24 sessions a year.This study targeted citizens over the age of 65. The exclusion criteria were as follows: Participants whose data regarding the Aid for Decision-making in Occupation Choice (ADOC) (n = 8) and questions about driving (n = 4) were missing; participants who had a history of stroke (n = 36), Parkinson’s disease (n = 1), and dementia (n = 8); and participants who had never owned a driver’s license (n = 208) in their lifetime.We questioned the participants about their present driving status and then divided them into two groups: the active driving (n = 549) group and the after driving cessation (n = 45) groups. The active driving group included people with a license, and the after driving cessation group included those who had returned their license (n = 27), who had not renewed their license (n = 2), and who had not returned their license, but were not currently driving (n = 16). In addition, the active driving group was operationally divided into three groups: high-frequency group , medium group , and infrequent group , and their characteristics were compared. Finally, data from 594 community-dwelling older adults  were analysed for this study . The ethIn this study, meaningful activities were operationally defined as “activities that individuals consider important in their daily life” . The ADORegarding psychosomatic function, we examined the participants’ depressive state ,9,10, coFrailty is a state of physical and mental decline due to aging, which involves the interaction of physical, cognitive, and social aspects. Physical frailty was evaluated for five items: weight loss, weakness, exhaustion, slowness, and low levels of activity, with reference to the definition of the Cardiovascular Health Study (CHS)  and the t-test for continuous variables, Pearson’s χ2 tests for categorical variables, and the Mann–Whitney U-test and Kruskal–Wallis test for ordinal variables. To exclude the effect of gender, we performed the same analysis only in women. In addition, the active driving group was operationally divided into three groups: high-frequency, medium, and infrequent groups, and statistical analysis was performed. We used one-way ANOVA for continuous variables, Pearson’s χ2 tests for categorical variables, and Kruskal–Wallis test for ordinal variables. Meaningful activities were analysed, including all selected activities from the first to fifth place. Further, the representative values of satisfaction and performance were taken as the median score of first to fifth place. All analyses were conducted using IBM SPSS Statistics 24.0 , and p values < 0.05 were considered statistically significant.We used Student’s p < 0.001, women: p < 0.001), while the grip strength and JST-IC scores in the after driving cessation group were significantly lower  compared with those in the active driving group. The proportion of those with apathy (p = 0.009), physical frailty (p = 0.001) and social frailty (p = 0.002) in the after driving cessation group was significantly higher compared with those in the active driving group. There was no difference in satisfaction (p = 0.266) or performance (p = 0.655) of meaningful activities between the two groups. Of the meaningful activity categories selected by the active driving and after driving cessation groups, the ratio that selected leisure was high in both groups  (p < 0.05), while domestic life in the after driving cessation group was significantly higher compared with that in the active driving group  (The characteristics of the study participants are listed in : 27.9%) . The wor < 0.01) . Regardi < 0.01) . In spec < 0.01) .p < 0.001) and JST-IC score (p < 0.001) were significantly lower, and the proportion of physical frailty (p = 0.001) and social frailty (p = 0.018) was significantly higher in the after driving cessation group compared with those in the active driving group (p < 0.05), and domestic life in the after driving cessation group was significantly higher than in the active driving group  (p < 0.007), and more apathy (p = 0.001) and social frailty (p < 0.025)  . In cont< 0.025) . As people get older, they may stop driving due to various reasons, such as deterioration in physical function. However, a driving interruption can be a turning point in their lives. Changes in the living environment due to interruptions in driving are affected by various factors such as physical and psychosomatic functions, personal factors, and environmental factors, and these complex interrelationships can affect daily life. In this study, we examined whether meaningful activities and psychosomatic function of community-dwelling older adults differ due to their driving status. We found that the active driving group valued work/education, while the after driving cessation group attached importance to domestic life. Moreover, the grip strength and JST-IC score were significantly lower in the after driving cessation group than in the active driving group. The proportion of apathy and physical and social frailty were significantly higher in the after driving cessation group than in the active driving group. In the active driving group, grip strength decreased, and social frailty increased as the frequency of driving decreased. As public transport in Tarumizu City is inadequate, it is challenging to live without a private car. Therefore, for older adults considering driving cessation in the future, it is necessary to support them considering their meaningful activities and intervene to maintain their physical activities.Regarding the psychosomatic functions of the older adults who stopped driving, it was found that their grip strength and activity ability were considerably reduced. Furthermore, the incidences of apathy and physical and social frailty were high. Thus, we think that various daily life activities are restricted by interrupted driving, which may cause a decrease in muscle strength and the ability to be active as well as an increase in apathy in older adults.Comparing the meaningful activities between both the groups, it was found that the active driving group attached high value to work/education, while the after driving cessation group attached importance to domestic life. As the active driving group was younger and had a higher proportion of men than the after driving cessation group, it was comprised of individuals who were the financial earners in their family. A previous study has reported that older people who retire from their full-time jobs have worse mental health (GDS-15) and Higher-Level Functional Capacity . TherefoPrevious studies have reported that low mileage while driving  and the As drivers drive less frequently, their physical function declines and their social frailty increases. This means that even those who are currently driving are likely to drive less often and experience interruptions, increasing the risk of reduced activity, apathy, and physical frailty. Previous studies have reported that lower Short Physical Performance Battery (SPPB) scores were consistently with lower driving exposure and increased driving cessation ,50. HoweAlthough driving cessation is associated with psychosomatic function in older citizens, pre-planning for driving cessation has been suggested to influence the quality of life of older persons . MoreoveThis study has several limitations. First, it is a cross-sectional study, and we cannot clarify whether our results are causes or results of driving cessation. Second, this study was carried out in one city, and we cannot deny the selection bias. Therefore, we need to perform high extensive and longitudinal studies to investigate the effect of driving cessation on meaningful activity and physical and social frailty. Third, the percentage of people after driving cessation in the final sample of the study was 8.2%, and the group sizes between active driving and after driving cessation were very different. This means that there is a higher scope for a wide variety of activities in the active driving group. However, in previous studies, the percentage of people who stopped driving was 9.0% , and 5.2In conclusion, we found that meaningful activity differed depending on the driving status; the active driving group valued work/education, while the after driving cessation group attached importance to domestic life. Moreover, in terms of physical and psychosomatic function, the after driving cessation group may be associated with weak muscle strength, apathy, and physical and social frailty. In addition, infrequent driving in the active driving group may give rise to an increasing number of older adults with social frailty. These results may be helpful in the pre-planning and support of driving cessation in older adults.


High-temperature superconducting (HTS) bulks can be used in electrical applications. Experimental characterization of large-size HTS bulks is a tricky issue. The relevant parameters for their application were directly measured in this study. This paper has three main aims. Firstly, features of YBaCuO bulks are presented. Secondly, an electrical motor application is developed using magnetic field shielding and trapping. Thirdly, the HTS bulks are characterized. Several classical methods were used, which are mainly magnetic methods only available for small samples. The complete penetration magnetic field and the critical current density were found to be the main parameters relevant for applications. An innovative entire HTS bulk characterization method is presented. This characterization method is useful for end users and engineers to better implement HTS bulks. CJ and can be magnetized to very high magnetic flux densities. The main applications of HTS bulks are levitation, cryo-magnets, electrical motors, and magnetic gears.High-temperature superconducting (HTS) bulks can be used in electrical applications as magnets or magnetic shields. Indeed, they have a high critical current density CJ. Different classical methods have been used for small samples [CJ on the magnetic field B and temperature of the HTS material. Different characterization methods exist, such as magnetization methods, measurements of susceptibility, or measurements of levitation force. In these classical characterization methods, the relationship between measurements and CJ is not direct and, thus, these are called indirect methods. On another hand, Mawatari [CJ, but it modifies the properties of the HTS sample in comparison with the entire HTS bulk. The main issue with these characterization methods is that there are valid only for small samples cut into entire HTS bulks. This is sufficient for material scientists and it allows comparing HTS materials, but it is not useful for applications. End users of HTS bulks, such as engineers or electrical engineering researchers, need characterization of the entire HTS bulks to optimally use them in applications. Hence, for real HTS bulks used in electrical applications, other methods are necessary, allowing characterization of the entire HTS bulks without cutting. Recently, the CAN company [CJ and n-value. It consists of the determination of the complete penetration magnetic field PB and a deduction of the critical current density CJ. This new method is original, quick, and direct for determining the critical current density Jc and n-value in bulk superconductors from magnetic field diffusion measurements [It is necessary to characterize this HTS bulks to optimally use them. This means the determination of the critical current density  samples ,19,20,21Mawatari  proposed company , buildin company  used picurements ,19,20,21This paper has three main aims. Firstly, features of YBaCuO bulks are presented and compared with respect to applications. Secondly, an HTS electrical motor application is presented. Lastly, the innovative HTS bulk characterization method is described. a–b plane of the copper-oxide layer. In the c-direction, perpendicular to the a–b plane, the electric conductivity is close to zero. Thus, HTS materials are clearly anisotropic.HTS bulks are composed of copper-oxide layers and a rare earth element as Yttrium . The supCJ are more than 100 A/mm2 at 77 K, and the size can be more than 5 cm diameter  was established, which allowed building large, single-grain HTS bulks . The prodiameter  with difCT (92 K for YBaCuO), critical current density CJ, and critical magnetic field CH. Because HTS materials are used at high temperature (T > 30 K), there is another important magnetic field, called the irreversibility magnetic field H*, between CH1, where the penetration of the magnetic field begins, and CH2, where the superconductivity disappears. If the magnetic field inside the HTS material is higher than this irreversibility magnetic field, the critical current density drops to zero. Thus, H* is the most important magnetic field parameter to know for electric applications as motors, because, in this case, a high electric current density and high magnetic field are simultaneously necessary to improve motor capability and efficiency.As a superconducting material, HTS bulks have three critical quantities: critical temperature HTS bulk can be used as a magnetic shield or permanent magnet in superconducting electrical machines.GREEN lab in France designed, built, and tested many HTS machines using a magnetic shield producing a magnetic field concentration.CJ, which decreases when temperature increases.The inductor of the first prototype built in GREEN was originally presented in . It usedFollowing this first machine, a collaboration began a few years ago between SAFRAN and GREEN to construct an HTS motor for aeronautic applications . In this second magnetic flux concentration motor , the HTSThe HTS YBaCuO bulk, submitted to a magnetic field and then cooled down, traps the magnetic field. This method is called zero field cooling (ZFC). It is possible to obtain 4 T on the surface of a YBaCuO bulk at 77 K (liquid nitrogen) and up to 17 T at 29 K  and 17.9One of the issues with this kind of HTS motor is the choice of whether to magnetize the HTS bulks inside the machine (in situ) or outside of the machine (ex situ). The prototypes already made used ex situ magnetization because it is the simplest option in terms of magnetization. However, many teams ,29,30,31CJ, the size of the HTS bulk, and the form of the applied magnetic field pulse [Trapping the magnetic field in the HTS bulk using the PFM method depends on the critical current density ld pulse ,29,30. IIn this section, the HTS bulk characterization method developed by us is presented; however, the complete penetration magnetic field is firstly defined.PB is generally linked to the Bean model [CJ or null in the superconducting material. With this model, the penetration depth Pd of the magnetic field in a superconducting infinite cylinder submitted to an axial applied magnetic field Ba is calculated asThe most used definition of the complete penetration magnetic field an model . In thisPd = R is the radius of the cylinder, the complete penetration magnetic field is defined byTherefore, if the magnetic field reaches the center of the infinite cylinder, where Pd, related to CJ, allows determining the capability of magnetic shielding. On the other hand, the complete penetration magnetic field PB allows determining the capability of magnetic field trapping of HTS bulks.For electrical motor applications using HTS bulk, the penetration depth Ba(t) does not matter with the Bean model; hence, we applied the following equation:The shape of Bo begins to increase with delay time PT when Ba reaches the complete magnetic field PB   is the equivalent of the pB formula given by different authors [For a cylindrical HTS bulk of length L and radius R, submitted to an applied magnetic field Ba(t) , the folan model :(4)BP=μ0 authors ,19,20,21PB and the geometric parameters of the cylindrical HTS pellet, CJ can be deduced with the help of Equation (4).Thus, from In the case of HTS used at “high temperatures” , a power law model (PLM) better represents the E(J) characteristic of the materials than the Bean model. The PLM is typically written asPB, CJ, and n-value of HTS bulks can be done by measurement and numerical simulation of magnetic field penetration [bV changes the distribution of the magnetic field and current density according to the power law (Equation (5)) instead of the Bean model [PB depends on the rise rate bV as follows:α = 1.2 and β = 3.4 for a typical HTS bulk size.The determination of etration . The infan model . Thus, BBa(t) (Ba(t) is a linear function of time. In our method, the complete penetration magnetic field is detected. To measure PB [Ba(t) had a constant rise rate bV of ~660 T/s. As shown in the red region of B0(t) does not have exactly the same shape as the beginning of Ba(t). This is due to the fact that this is not a single HTS bulk but two bulks separated by the Hall probe thickness. The influence of the thickness of the Hall probe e is presented below. The determination of the penetration time PT is done as follows: the measured magnetic field curve at the pellet center is modified around PT to be a copy of applied magnetic field Ba(t)  . Ba(t) iasure BP ,19,20, aPMB and the theoretical PB from (Equation (6)) is as follows:The influence of Hall probe thickness e  was calcPMB was around 1 T (red arrow). PB was deduced from PMB using Equation (7) and knowing e and L. CJ was deduced from PB with Equation (6) and with n taken as equal to 50, giving a result of ~110 A/mm2.For the two YBaCuO bulks presented in PMB and the CJ determination, as shown in PMB ; as such, improvements will be necessary. HTS bulks are very promising for electrical motor applications as super magnets or magnetic shields. HTS bulks are built and sold by industrial companies. Electrical motor prototypes were built and successfully tested by different teams using a shielding effect and HTS permanent magnets. The magnetization and characterization of these HTS bulks are necessary to control their use in electrical motor applications. A new direct


All participants received 30 min of training each time, five times per week, for six weeks. Lower extremity muscle strength of tibialis anterior (LEMTA) was evaluated using a digital muscular dynamometer. The Medical Research Council (MRC) scale was used to evaluate muscle strengths of the hip joint, knee joint, and ankle joint. For balance ability test, the center of pressure (COP) movement distance and limited of stability (LOS) were measured using BioRescue. Results: LEMTA, MRC scale, balance ability were significantly more improved in the CSMT group than in the control group (p < 0.05). Conclusions: Our findings indicate that CSMT is beneficial and effective for improving muscle strength of the lower extremity and balance ability of post-stroke patients.Background: Sensory motor impairment, the most common neuromuscular condition in stroke patients, often contributes to muscle weakness and imbalance. Objective: The purpose of this research was to investigate the effects of cognitive sensory-motor training (CSMT) on the muscle strength and balance ability in post-stroke patients. Methods: Thirty-five participants after stroke were randomly assigned to the CSMT ( Although functional limitations and disability aspects caused by stroke are different depending on the area and degree of damage, stroke patients generally show problems such as cognitive disorder, motor and sensory impairments and lower extremity dysfunction . As a reCSMT was first proposed by Professor Carlo Perfetti. It is widely known in the rehabilitation program as Perfetti’s Method ,4. It isIn general, methods used in neurorehabilitation are widely used, such as transcranial direct current stimulation , functioRecent studies on improvement of function have reported that motor function is closely related to cognitive function . The purThis study was designed as a single blind randomized study. The subjects of this study included 35 hospitalized patients with stroke who were undergoing physical therapy at K hospital located in Gyeonggi-do. Inclusion criteria were: (1) those who could walk for at least 10 m, (2) those who had a stroke over 6 months ago, (3) those who could communicate, (4) Mini Mental State Examination-Korea (MMSE-K) score was above 24, (5) Brunnstrom recovery stage 2 to 4, (6) those who did not have a problem with walking due to other diseases other than stroke, (7) those with sensory defect in the lower extremity, and (8) those who had voluntarily signed an informed consent form prior to the this study. Exclusion criteria were: (1) vestibular organ or cerebellum-related disease, (2) visual impairment or hearing defect, (3) severe cognitive decline and aphasia, (4) those who had difficulty in conducting the study and those who had hemineglect.This study had an assessor-blinded and randomized controlled trial design. In accordance with the Helsinki Declaration, this study was conducted after obtaining approval from the Institutional Review Board of Sahmyook University. The consent number for bioethics study is 2-1040781-AD-N-01-2016009HR.n = 19) and a control group (n = 20) according to the purpose of this study. Groups were selected by randomization using a computer to minimize selection bias . During the study period of 6 weeks, two subjects from the CSMT group and two subjects from the control group did not receive allocated intervention. Thus, 35 subjects finally participated in this study  for calculation of the sample size, which was determined on the basis of ability to detect a clinically significant improvement in the outcome measures from a pilot study (least 17 participants for each group), and set the effect size as 1.01, the alpha error as 0.05 and power as 0.80.The purpose of applying CSMT was to improve sense of sitting condition, trunk stability, and lower extremity movement. CSMT was conducted for 30 min, 5 times a week for a total of 6 weeks in this study. For the cognitive sensory-motor program using visual sense, somatosensory, and spatial task as sensory cognitive tasks, an exercise program was set up to distinguish distance and direction. Based on previous studies of Chanubol et al.  contentsIn order to enhance the effect of exercise training, the training was conducted in an independent place without noise so that an unobstructed environment was provided while maintaining a proper temperature for conducting the training. From the beginning to the end of the study, the training was carried out with the same contents by the same investigator.For the control group, Bobath’s neurodevelopmental therapy and proprioceptive neuromuscular facilitation , range or = 0.90~0.96 and r = 0.76~0.97, respectively  with a unit of cm2. When the subject was standing on the force plate, the direction of the arrow appeared randomly on the computer screen. The subject then moved the COG in the direction of the arrow that appeared randomly on the computer screen. The larger the measured value, the better the dynamic balance ability. All study subjects repeated this three times. The mean value of the three measurements was then calculated.To measure the balance ability of participants, we used a balance ability measurement and training system . In the balance assessment, the following four parameters of eye open and close were evaluated: Romberg eye open surface area (REOSA), Romberg eye open average speed (REOAS), Romberg eye close surface area (RECSA), and Romberg eye close average speed (RECAS). They were measured with open eyes in a standing position. Both feet were supported by a force platform. COG movement distance was measured for 60 s. The unit of COG movement distance for 60 s with eyes closed was cm and the unit of surface area was mmt-test for dependent variables such as age, height, body weight, MMSE-K, and year of onset before training. The normality test was performed with Shapiro–Wilk test. The effects of intervention LEMTA, MRC, and the balance ability test were examined using the two-way repeated measures ANOVA analysis. The pre- and post-test (time) were the within-participants factors. The group-by-time (between-factors) were the CSMT and control group results. When significant differences were observed in group-by-time (main effects or interactions) analyses, the independent-test and paired t-test were used post hoc analysis. All statistical significance levels of data were set at α = 0.05.The SPSS  was used for all statistical analyses of this study. Among general characteristics of the two groups, gender, diagnosis, paralyzed side, spasticity, and encephalopathy area were analyzed by Chi-square test. Homogeneity was analyzed by Independent F = 6.760, p = 0.014) and MRC score . LEMTA and MRC showed significantly more in the CSMT group than in the control group. Significant within-participant changes were LEMTA  and MRC score  (A = 0.000) .F = 10.066, p = 0.003) and REOAS . REOSA and REOAS showed significantly more differences in the CSMT group than in the control group. Significant within-participant changes were REOSA  and REOAS  (= 0.000) .F = 6.501, p = 0.016) and RECAS . RECSA and RECAS showed significantly more differences in the CSMT group than in the control group. Significant within-participant changes were RECSA  and RECAS  (= 0.000) .F = 5.514, p = 0.025). After training, LOS showed significantly more changes in the CSMT group than in the control group. Significant within-participant changes were LOS  (= 0.000) .This study was conducted to investigate effects of CSMT on muscle strength of the lower extremity and balance ability of stroke patients. CSMT was performed for 6 weeks to analyze its effects on lower extremity muscle strength and balance ability of stroke patients.To our knowledge, this is the first time that CSMT has been applied to the lower extremities in stroke patients. The CSMT method requires a lot of time for the therapist to perform a treatment directly 1: 1 in an independent space. This study was designed to make the patient feel a sensation and to function well cognitively and make exercise and movement better than in an optimal independent space. The therapeutic goal for patients with upper motor-neuron lesion was to make movement for sensory recovery, brain activation, and correct movement input sequence while interacting with each other. According to results of a previous study, the CSMT method can be used in a randomized controlled manner focusing on the recovery of the upper limb function of stroke patients . HoweverThe advantage of this study was that the method of applying CSMT to stroke patients with hypoesthesia and dysfunction in lower extremity was a very interesting treatment method. Another important feature was that the cognitive sensory motor method provides various information input to the subjects in three ways: proprioception, somatic sense, and spatial sense. Results confirmed that it was a good method for increasing learning effects as well as motivation by applying various types of senses. The cognitive sensory exercise in this study synchronized muscle contraction with the exercise intention, thus enabling participants to induce the formation of an augmented sensory feedback circuit for performing exercise tasks .The most common exercise impairment after the onset of stroke is weakness of muscle strength. Muscular weakness is a factor that limits functional rehabilitation of stroke patients. It is the target of treatment for performing functional movement. It is an essential factor for improving balance . Saeys eThe CSMT group showed statistically significant differences up to 6 weeks compared to the control group in the muscle strength of anterior tibialis muscle and MRC scale. This means that the application of CSMT can change the sensory input to the muscle and joint receptors as well as skin receptors on the patient’s soles. Such change in sensory input from these receptors can induce the patient’s motor system due to motor function rehabilitation . In addiBalance is the ability to maintain body weight within the base of support with minimal postural sway . The conIn this study, the CSMT group showed statistically significant differences up to 6 weeks compared to the control group in balance ability. Lim  has repoThe intervention of this study strengthened joint mobility, normalization of neuromuscular control, and unconscious motor response to afferent stimulation. Thus, the cognitive motor rehabilitation exercise program was an appropriate and efficient feedforward control so that sensory input information matched current characteristics of the body. It is thought that the balance ability is improved by constantly updating the body’s cognitive ability to the most recent state while being adjusted. This study has some limitations. It is difficult to generalize results because the number of participants who participated in this study is too small. Cognitive function, sensory, muscle fatigue, range of motion and spasticity were not tested. Various types of scientific studies focusing on rehabilitation programs for improving lower extremity muscular strength and balance ability in stroke patients need to be carried out in the future.CSMT could significant improve muscle strength of lower extremity and balance ability for stroke patients. Thus, it can be applied as a program to increase muscle strength of lower extremity and balance ability of stroke patients who exhibit difficulty in function recovery when planning a training program for stroke patients. Future research may investigate the effects of various interventions combined with CSMT and contribute to integrating sensory, motor, and cognitive effects in stroke patients.


The programmed cell death protein 1 inhibitor pembrolizumab, an immune checkpoint inhibitor, has subsequently been approved for the treatment of a wide variety of malignant tumors. Compared with conventional chemotherapy, immunotherapy is associated with a unique set of immune reactions, known collectively as immune-related adverse events. Although often mild, dermatologic toxicity can occasionally be high grade and potentially life-threatening. Here we describe a rare case of bullous pemphigoid (BP) associated with pembrolizumab. A 79-year-old male patient presented with scattered erythema, papules, blisters, and pruritus after pembrolizumab treatment. Then, the rash gradually aggravated and spread to the whole body. The extensive edematous erythema, blisters, bullae, and blood blisters were loose and easy to rupture, forming an erosive surface and with pruritus and obvious pain. The hemidesmosomal protein BP180 (type XVII collagen) was detectable in the serum, and the histological examination diagnosis was bullous pemphigoid. After 10 days of glucocorticoid  treatment, new blister formation ceased. We need to increase the awareness on and facilitate the earlier identification of the cutaneous adverse effects of BP with immunotherapy so that treat can begin early in order to limit the duration and severity of toxicity. Pembrolizumab is a humanized monoclonal antibody IgG4 programmed cell death protein 1 (PD-1) antagonist. As a new drug of immune checkpoint inhibitor, pembrolizumab has shown great promising prospects in clinical antitumor immunotherapy and has rapidly become the first-line therapy for a variety of advanced malignancies. It has been recommended in antitumor guidelines of many countries and opened a new era of tumor immunotherapy –4. Here In May 2019, a 79-year-old male patient underwent resection of the left kidney and ureter for invasive high-grade papillary urothelial carcinoma. The tumor size was 1.2 × 1 × 0.2 cm, and the tumor TNM scale was T1N0M1. In January 2020, multiple round nodules of different sizes can be seen in both lungs by CT and PET-CT, with a smooth boundary. The largest one is located in the left lower lung, about 2.2 × 1.8 cm. From February to September 2020, he had received 10 cycles of pembrolizumab therapy  because of lung metastatic carcinoma. From April 2020, erythema and pimples accompanied by pruritus appeared successively on the trunks and limbs of the patient. After symptomatic treatment, the rash subsided and appeared repeatedly. From November 2020, the rash aggravated gradually; macroscopically, the lesions appeared as strained blisters filled with serous fluid and blood on erythematous skin, spreading throughout the body. The blood bullae were big, loose, and easy to break, forming the erosive surface . Direct immunofluorescence did not show a deposition of immunoglobulins at the cell surface of keratinocytes. By employing PET-CT, multiple hypermetabolic metastases in the lungs were detected on January 10, 2020, while the PET-CT image taken on November 19, 2020 showed that the original lesions were not clearly displayed. This suggested that immunotherapy was effective in the early stage, and the tumor achieved clinical complete remission (CR) after the treatment. No typical malignant hypermetabolic lesions were found in the rest of the body, so PNP can be excluded. BP can be caused by some drugs, including furosemide and anti-DPP4 inhibitors. This patient was not prescribed with these drugs.After 3 days of glucocorticoid treatment , the cutaneous lesions improved. In some parts, the blister fluid was absorbed and the skin surface shrunk, the erosive surface began to scab and heal, and the color of erythema became pale. After 10 days, all the blisters disappeared, and new bullae formation ceased. All the superficial erosions were scabby and most of the scabs fell off, leaving dark red pigmentation spots , the skin lesions were not healed  for the publication of any potentially identifiable images or data included in this article.XZ and DS contributed to data collection, data analysis, data interpretation, and manuscript preparation. DW and LZ contributed to data analysis and data interpretation. RW contributed to data collection. XZ contributed to data review and interpretation. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background & Aims: Gastric cancer is the common malignancies from cancer worldwide. Endoscopy is currently the most effective method to detect early gastric cancer (EGC). However, endoscopy is not infallible and EGC can be missed during endoscopy. Artificial intelligence (AI)-assisted endoscopic diagnosis is a recent hot spot of research. We aimed to quantify the diagnostic value of AI-assisted endoscopy in diagnosing EGC.Method: The PubMed, MEDLINE, Embase and the Cochrane Library Databases were searched for articles on AI-assisted endoscopy application in EGC diagnosis. The pooled sensitivity, specificity, and area under the curve (AUC) were calculated, and the endoscopists' diagnostic value was evaluated for comparison. The subgroup was set according to endoscopy modality, and number of training images. A funnel plot was delineated to estimate the publication bias.Result: 16 studies were included in this study. We indicated that the application of AI in endoscopic detection of EGC achieved an AUC of 0.96 , a sensitivity of 86% , and a specificity of 93% . In AI-assisted EGC depth diagnosis, the AUC was 0.82, and the pooled sensitivity and specificity was 0.72 and 0.79. The funnel plot showed no publication bias.Conclusion: The AI applications for EGC diagnosis seemed to be more accurate than the endoscopists. AI assisted EGC diagnosis was more accurate than experts. More prospective studies are needed to make AI-aided EGC diagnosis universal in clinical practice. Gastric cancer is ranked as the third leading cause of death from cancer worldwide . Most gaIn the past decade, the application of artificial intelligence (AI) in medicine has attracted extensive attention. AI-assisted endoscopic diagnosis is a hot spot of research. AI refers to the capacity of a computer to execute a task associated with intelligent beings, such as the “learn” function that mimics the cognitive ability of human beings . AI subfDeep learning, which was initially applied in the image processing field in 1998, refers to the application of layers in non-linear processing based on machine learning algorithms used for feature extraction and transformation . Neural To date, the existing data on the diagnostic value of AI for EGC diagnosis are scattered. Jin et al.  reviewedElectronic databases  were searched from initiation to November 2020 using presupposed search terms. The following medical subject terms and keywords were used: “endoscopy,” “Endoscopic Diagnosis,” “early gastric cancer,” “artificial intelligence,” “computer-assisted diagnosis,” “Deep learning,” and “Convolutional neural network.” The full texts of potentially appropriate studies were then reviewed after the screenings of citations and abstracts exported from the electronic databases. The search strategy was shown as follows: (1)  OR (computer-assisted diagnosis [Title/Abstract]) OR (Deep learning [Title/Abstract]) OR  (2) (endoscopy [Title/Abstract]) OR (Endoscopic Diagnosis [Title/Abstract]) OR (early gastric ancer [Title/Abstract]) (3) (1) AND (2).The eligible studies fulfilled the following criteria: (1) the study was a diagnosis test about AI application in endoscopy for EGC diagnosis. Diagnosis test included AI detection of EGC from other gastric disease or distinguishment of invasion depth; (2) the absolute numbers of true-positive, false-negative, true-negative, and false-positive observations for EGC diagnosis were reported directly or were able to be calculated; (3) the study provided clear information about the database and number of images; (4) the study clearly described the CAD or CNN algorithms and the process applied in the EGC diagnosis.Two reviewers  independently extracted information, including the author, publication year, region, study type, endoscopy modality, algorithm gold standard and dataset, and used the quality assessment of diagnostic accuracy studies-2 instrument to assess the quality of the study . DivergeI2 values indicated significant heterogeneity. Under this situation, a random-effects model would be applied, and subgroup analysis and influence analysis were performed. A summary receiver operating characteristic (ROC) curve was plotted  was used for all statistical analyses. Graphpad Prism 8.2.1 was used to delineate the histogram. The TP, FP, FN, and TN observations of each study were input, and the pooled sensitivity and specificity with the 95% confidence intervals (CIs) for EGC diagnosis with AI were thus calculated. The forest plot was delineated. The inconsistency index (I2) test was used to evaluate the heterogeneity between studies using sensitivity . A fixed plotted . The areA total of 3,714 studies were retrieved after the search. After removing duplicated studies and excluding improper studies, 17 studies were reserved in this systematic analysis. While Ling et al.  distingu2 value of 0.98, thus the random effect model was applied. The pooled sensitivity was 86% , and the specificity was 93% . While the AUC, sensitivity and specificity of AI-assisted depth distinction was 0.82 , 72% , and 79% . The forest plots of sensitivity, specificity of AI detection and depth distinction are shown in p-value of 0.81 showed the absence of publication bias for the included studies , while that of WLE was 73% , and the specificity was 96%  and 93% .When the number of training images was more than 10,000, the sensitivity and specificity were 88%  and 94% , respectively, more than that of the sensitivity 85%  and specificity 93%  of the group that had >10,000 training images.For the control group, sensitivity and specificity of the expert endoscopist vs. non-expert endoscopist diagnosis were 79%  vs. 73% , 85%  vs. 83% , respectively. Here, the general expert endoscopists were those who had clinical experience with endoscopy examination for more than 10 years. Japanese researchers published a minimum required standard for the “systematic screening protocol for the stomach,” which comprised 22 images of the stomach to precisely discover suspicious cancerous lesions . In 2016Deep learning , 48, whiApplication of AI recognition with endoscopic images to detect the depth of wall invasion of gastric cancer was initially reported by Keisuke Kubota with an accuracy of 64.7% . Soon afThis is the first meta-analysis on the performance of AI on EGC diagnosis with endoscopy. In this article, we indicated that the application of AI in endoscopic detection of EGC achieved an AUC of 0.96 , a sensitivity of 86% , and a specificity of 93% , which manifested a more accurate diagnostic ability than independent detection by endoscopists, while the depth distinction was dissatisfied with a sensitivity, specificity and AUC of 0.82 , 72% , and 79% . The common reasons for misdiagnosis were lesions of gastritis or flat or depressed texture and anatomical structure which was hard to identify. The cancer invasion depth was classically distinguished by morphologically evaluating several findings such as the concentration of stomach wall folds, the marginal ridge, the elasticity and thickness of the lesion, and the presence of variant of the stomach wall due to the volume of insufflation air in the stomach with WLE –54. FurtFor the algorithm model, Simonyan et al.  investigThe endoscopic image modality of validation set should be same to the training set. For training images from different endoscopy modalities, the sensitivity of studies using images from NBI seemed to be better than those using images from WLE (96 vs. 93%). A model which was trained with NBI images could only recognize NBI images in practice. However, a multicenter randomized controlled trial that compared a non-magnifying NBI with WLI indicated no significant difference in gastric cancer detection . AlthougFor the number of training images, it seemed that the more images the machine trained, the more accurate the AI detection would be. The concept that a large number of images are a prerequisite to structure a learning model was also certified in the research conducted by Seguí et al.  for motiNeural networks have the potential capacity for clinical practice and can be significantly popularized in the gastrointestinal field. However, CNN detection is temporarily in the stage of research. This study also had some limitations. A limited number of available studies fit the inclusion criteria since the novel technology has just been developed in recent years. Thus, the subgroup results were not completely reliable due to the limited number of studies. All the included studies were retrospective, which may lead to selection bias of included images, particularly in the validation dataset. In addition, few studies provided a solution to multiple gastrointestinal abnormalities as comparison, while most studies only researched the detection of a single abnormality, including Barrett's esophagus, Helicobacter pylori infection, early gastric cancer, atrophic gastritis, etc. –70, whicTo overcome these limitations, several projects can be carried out in the future. More prospective studies can be designed for strict images, including criteria, high-definition image extraction and expert endoscopist involvement to prove higher level evidence. Luo et al.  has carrThis is the first meta-analysis to summarize current evidence of AI applications in EGC diagnosis. The AI applications seemed to be more accurate in parts of EGC detection than the endoscopists. The VGG-16, SSD, and SVM classifier models probably performed better according to the limited studies. When the number of training images is expanded, the accuracy will be improved. More strictly designed perspective studies with different reliable CNN algorithms are needed to make AI universal in clinical practice.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/KJ: study concept and design and analysis and interpretation of data. XJ and YW: acquisition of data. SW, KN, ZZ, SJ, and PLiu: literature search. XJ, JP, and YH: figure processing. PLi and SL: critical revision of the manuscript for important intellectual content. FL: study supervision. All authors contributed to the article and approved the submitted version.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.