Although some placenta-derived products are already used for tissue regeneration, the human chorion membrane (HCM) alone has been poorly explored. In fact, just one study uses decellularized HCM (dHCM) with native tissue architecture  suspension creation) as a substrate for cell differentiation. The aim of this work is to fully characterize the dHCM for the presence and distribution of cell nuclei, DNA and ECM components. Moreover, mechanical properties, in vitro biological performance and in vivo biocompatibility were also studied. Our results demonstrated that the HCM was successfully decellularized and the main ECM proteins were preserved. The dHCM has two different surfaces, the reticular layer side and the trophoblast side; and is biocompatible both in vitro and in vivo. Importantly, the in vivo experiments demonstrated that on day 28 the dHCM starts to be integrated by the host tissue. Altogether, these results support the hypothesis that dHCM may be used as a biomaterial for different tissue regeneration strategies, particularly when a membrane is needed to separate tissues, organs or other biologic compartments. The human placenta is usually considered a biological waste. Nevertheless, it is consistently available from full-term births and it is also a source of mesenchymal stem cells, growth factors and extracellular matrix (ECM) proteins ,2.Some placenta-derived products are already used for tissue regeneration ,11,12,13Decellularized HAM alone is widely characterized and studied and has been shown to induce osteogenic differentiation of human dental apical papilla cells , to be aThe purpose of this study is to fully characterize the dHCM for the presence and distribution of cell nuclei, DNA and ECM components. Finally, the mechanical properties, and the in vitro and in vivo biocompatibility of dHCM were characterized envisioning its use as an ECM-based scaffold able to guide tissue regeneration, particularly when a membrane is needed to separate tissues, organs or other biologic compartments.Human placentas used in this study were collected from elective and term cesarean sections performed in the Obstetrics Department of the Hospital de Braga. The study follows a protocol approved by the ethical committee of the Hospital de Braga and of the University of Minho  and following all the international best practices for research with human biological samples. An informed consent was signed by all the donors. Sterile conditions were maintained during all processing steps. Placentas were stored in Dulbecco’s phosphate-buffered saline (D-PBS) with 10% antibiotic/antimycotic  at 4 °C for a maximum of 1 day. HCM was separated from the amnion, washed with phosphate-buffered saline (PBS) to remove any blood and stored at −80 °C until further use.As previously described by us , HCM werMembranes were air dried and weighed and total DNA from both native and decellularized HCM (dHCM) was extracted using the DNeasy Blood and Tissue Kit , according to manufacturer’s instructions. The quantification of double-stranded DNA (dsDNA) was performed using the Quant-iT PicoGreen dsDNA Assay Kit , according to manufacturer’s instructions. Electrophoresis was performed to assess the size of the DNA fragments, using a 1% agarose gel and GeneRuler DNA Ladder Mix . Four independent samples were used in each condition.The samples were fixed in 10% neutral-buffered formalin at 4 °C (for at least 24 h), embedded in paraffin, and 5 μm thick transverse sections were cut with a microtome. Histochemical stains such as hematoxylin and eosin (H&E) and Masson’s trichrome were performed in the samples. For H&E staining, samples were stained with hematoxylin  for 1 min, washed for 30 s and stained with eosin for 10 min . For Masson’s trichrome staining, slides were submitted to Azure B solution for 5 min, stained with hematoxylin for 5 min and washed in picric ethanol for 5 min. After that, samples were stained in Biebrich Scarlet-Acid Fuchsin for 15 min, submitted to 1% phosphomolybdic acid for 5 min and to Aniline Blue for 4 min. After each staining, all slides were washed with water, let to dry and rinsed with alcohol, cleared in xylene and mounted in Entellan rapid . Slides were observed under an optical microscope with a coupled digital camera . At least three independent samples were used in each condition.Samples were fixed with 2.5% glutaraldehyde in PBS. After three PBS washes, samples were dehydrated with increasing concentrations of ethanol (10% to 100%). Samples were air dried and mounted in SEM pins using carbon tape. The samples were coated with gold using a Sputter Coater . Micrographs were collected with a scanning electron microscope with EDS . At least three independent samples were used in each condition.Initially, dry samples were weighed and then were immersed in D-PBS or culture medium. At different time-points , samples were weighed immediately after the excess of liquid was removed by putting them between two pieces of filter paper. Samples were reimmersed in liquid until the next time-point. The process was repeated until the equilibrium was reached (stable percentage of water uptake). Six samples were used in each condition.The collagen content of HCM, dHCM and trophoblast layer (TL) was extracted and quantified using the Sircol Collagen Assay Kit  for soluble collagen and the Sircol Insoluble Collagen Assay Kit  as described before  and accoSulfated glycosaminoglycans (GAGs) content of HCM, dHCM and TL was quantified as previously described . SamplesSoluble protein was extracted from HCM and dHCM using Tissue Extraction Reagent I  with a protease inhibitor cocktail . The soluble protein content was determined using Protein Assay Dye Reagent Concentrate , according to manufacturer’s instructions.The SDS Gel Preparation Kit  was used to prepare the 4% stacking gel and 9% running gel. For each sample, 0.5 μg/μL of protein was loaded in the respective well. Following SDS-PAGE, the gel was stained with Coomassie Blue R-250  and an image was obtained using a Transilluminator . At least three independent samples were used in each condition.® Universal ABC Elite® Kit  was used as a secondary antibody, in accordance with manufacturer’s instructions. Finally, incubation was revealed using a Peroxidase Substrate Kit (DAB) . Extraction buffer without samples was used as a negative control. Collagen type I , collagen type IV , fibronectin  and laminin  were used as positive controls. At least three independent samples were used in each condition.One drop of each sample of soluble protein was placed in a nitrocellulose membrane. After drying, membranes were incubated for 1 h with 5% BSA, with agitation, at room temperature. Subsequently, membranes were incubated with primary antibody:mouse anticollagen type I 1:1000 ; rabbit anticollagen type IV, 1:500 ; rabbit antifibronectin 1:500 ; and mouse antilaminin, 1:500 . After overnight incubation, membranes were washed 3× for 5 min with Tris Buffered Saline (TBS) with Tween 20 and then the R.T.U. VECTASTAIN® Universal ABC Elite® Kit  was used, in accordance with manufacturer’s instructions. Incubation was revealed using a Peroxidase Substrate Kit (DAB) . Samples were counterstained with hematoxylin and mounted in an aqueous mounting medium. Slides were observed in an optical microscope with a coupled camera . At least three independent samples were used in each condition.Immunolocalization of different proteins, such as collagen type I, collagen type IV, fibronectin and laminin, was performed in paraffin-embedded samples sectioned at 5 μm, as previously described for collagen type II . BrieflyStatic mechanical properties were assessed using universal mechanical testing equipment  equipped with a 1 kN load cell. Nine samples of HCM and dHCM were cut in pieces of 20 × 5 mm and mounted in specific cassettes (to prevent the clamping system from damaging the samples), and the specimens were hydrated. The strain rate was defined at 5 mm/min and a 10 mm gauge length was used in tensile tests. Tests were finished when the specimens were ruptured.2. After reaching 80% of confluence, the cells were seeded into inserts. dHCM were mounted in cell crown inserts for 24-well plates . Millicell hanging cell culture inserts, Polyethylene terephthalate (PET) 0.4 µm for 24-well plates , were used as control. Both inserts were immersed in culture medium overnight before cell seeding. EA.hy926 and MRC-5 cells were seeded on the inserts with a density of 20 × 103 cells/cm2. Metabolic activity was evaluated by MTS assay . Three independent assays for each cell line were performed.Human umbilical vein endothelial cell line EA.hy926 and human lung fibroblast cell line MRC-5 were cultured in complete medium (Dublecco’s Modified Eagle’s Medium (DMEM) with 10% fetal bovine serum  and 1% penicillin/streptomycin  in T150 flasks at 37 °C in a humidifier incubator with 5% COThe experiments were performed in male BALB/c mice aged 9 weeks old , and a total of 20 animals were used. Animals were housed five per cage in a limited-access rodent facility. Food and water were available ad libitum and animals were maintained in a climate-controlled room (22.0 ± 0.5 °C temperature) in 12/12 h light/dark cycle with lights on at 8:00 a.m. The experimental protocol was approved by the Institutional Ethical Commission and followed the European Community Council Directive concerning the use of animals for scientific purposes. Before surgery, animals were exposed to handling twice a day. All efforts were made to minimize animal suffering and to use only the number of animals necessary to produce reliable scientific data.® and two skin incisions were made (each 0.5 cm length) in each mouse. A sample of the dHCM was implanted subcutaneously in each of the pockets and the incision was closed using 5-0 sutures . Empty defects were used as controls, either in the control group  and in the contralateral side of the pocket containing the material. After the procedure, the anesthesia was reversed with a subcutaneous injection of antisedan and the animals were monitored until fully awake (eating and grooming). After 4, 10 or 28 days, animals were euthanized by pentobarbital injection, and dHCM membranes and surrounding tissues were explanted for subsequent histological analyses.The main goal of this in vivo study was the assessment of the biocompatibility of dHCM membranes in healthy animals. BALB/c mice were anesthetized by an intraperitoneal injection of Domitor (medetomidine 0.5 mg/kg) plus Imalgene (ketamine 75 mg/kg). The dorsum of the animals (implantation area) was shaved, cleaned and sterilized with Betadinep < 0.05 was considered statistically significant.Statistical analysis was performed using GraphPad Prism 7. The Shapiro–Wilk test was used to assess data normality. When data followed a normal distribution, parametric tests were used, namely the unpaired t-test and two-way ANOVA test followed by Tukey’s multiple comparisons test. When data did not follow a normal distribution, the Mann–Whitney test was used. p = 0.0002) in dHCM when compared with HCM .The swelling behavior of dHCM in culture medium and PBS is shown in p = 0.0045 (HCM vs. dHCM); p < 0.0001 (HCM vs. TL); p = 0.0006 (dHCM vs. TL)). Soluble collagen content was 6.33 ± 0.92 μg/mg of dry tissue in HCM, 3.70 ± 0.46 μg/mg of dry tissue in dHCM and 0.80 ± 0.06 μg/mg of dry tissue in TL. This tendency was not observed in insoluble collagen content (p < 0.0001) and TL . No statistically significant differences were observed between HCM and TL (p = 0.2850). The total collagen (soluble and insoluble) amount was significantly higher in dHCM (142.30 ± 20.07 μg/mg of dry tissue) when compared with HCM  and TL . No differences were observed between HCM and TL (p = 0.1406). For sulfated GAG quantification (p < 0.0001) and TL . Sulfated GAGs content in HCM was also significantly higher than in TL (p < 0.0001).The dHCM composition was assessed using SDS-PAGE, dot blot and immunolocalization of proteins. SDS-PAGE gel showed similarity among dHCM samples A, sugges content E where dfication F, dHCM pp < 0.0001).Mechanical properties were assessed in hydrated samples. Nine stress–strain curves are represented in p > 0.05) and with the MRC-5 cell line (p > 0.05). On day 3, the dHCM reticular layer side presented a significantly lower metabolic activity in both the EA.hy926 (p > 0.05 vs. dHCM trophoblast side) and the MRC-5 cell line (p < 0.05). Nevertheless, no differences were observed between CTR and both dHCM sides in the EA.hy926 cell line (p > 0.05) and between the CTR and dHCM trophoblast side in the MRC-5 cell line (p = 0.1365). Regarding day 6, CTR condition outperformed both dHCM sides with the EA.hy926 (p < 0.05) and the MRC-5 cell line (p < 0.05). No differences were observed between dHCM sides with both cell lines (p > 0.05). To further evaluate the biocompatibility of dHCM in vivo, dHCM membranes were subcutaneously implanted in BALB/c mice. After four, 10 and 28 days, animals were sacrificed and the tissue surrounding the dHCM membranes was collected for histological characterization. All animals survived during the period of the in vivo experiments. These animals did not demonstrate any mortality and infection throughout the study period, and the implantation of dHCM membranes did not produce any surgery-related and implantation-related abnormalities. As observed on To evaluate the biocompatibility of dHCM in vitro, metabolic activity of EA.hy926 and MRC-5 cell lines were analyzed. Commercial inserts were used as controls (CTR). In all conditions, the metabolic activity of both EA.hy926 A and MRCIn this study, a natural biomaterial was obtained resulting from a decellularization protocol previously developed by us for the HCM alone . dHCM waIn order to avoid cell and host adverse response, a decellularized tissue should (1) lack nuclear material (stained with DAPI); (2) have no DNA fragments larger than 200 bp; and (3) present an amount of dsDNA/mg of dry tissue less than 50 ng . All thep < 0.0001), as already demonstrated [Young’s modulus represents the stiffness or resistance to elastic deformation under load of a biomaterial, and the ultimate tensile strength characterizes the resistance of a material to fracture. Both Young’s modulus and the ultimate tensile strength are higher in dHCM when compared to HCM  and dHCM inserts (0.95 cm2) might influence cells to behave and organize in different ways [The cytocompatibility of dHCM was investigated using two human cell lines of endothelial cells (EA.hy926) and fibroblasts (MRC-5). Commercial inserts were used as reference. SEM micrographs C,D and ient ways , resultiECM scaffolds, as dHCM, are envisioned to help and accelerate the remodeling of injured tissues in vivo . By its In this work, the dHCM was fully characterized, for the first time, for the presence and distribution of ECM components, mechanical properties and in vivo and in vitro behavior. It was demonstrated that the dHCM is in accordance with the established criteria for decellularized tissues to avoid cell and host adverse reactions . As SIS PCT/IB2020/056426.


Despite availability of clinical guidelines, underdiagnosis, undertreatment, and poor adherence are still significant concerns in allergic rhinitis (AR) therapeutic management. We investigated clinical practice patterns and prescribing behavior of Italian healthcare professionals (HCPs) specialized in AR.One-hundred allergologists, 100 ear, nose and throat (ENT) specialists, and 150 general practitioners (GPs) were recruited. The survey assessed: socio-demographic, work experience, monthly caseload, prescription drivers. Next, HCPs were invited to retrospectively recover patients’ clinical data to investigate: AR clinical characteristics, therapy management, prescription patterns, patient adherence. Descriptive statistics, Chi square, One-Way analysis of variance, and Two-Way Analysis of Variance were performed.Allergologists visited more AR patients (31% of monthly caseload) than ENTs , while GPs’ caseload was the lowest (6%). Clinical information of 2823 patients were retrieved of whom 1906 (67.5%) suffered from moderate/severe AR (discomfort score: 7.7 ± 1.3) and 917 (32.4%) from mild AR (5.7 ± 1.9). About one-third of mild patients had a discomfort score ≥ 7. Main prescription drivers were “effective on all symptoms” (54.3% patients) and “quick symptom relief” (47.8%), whereas minor drivers were “affordable price” (13.4%) and “refundable” (8.7%). The most prescribed drugs were antihistamines and intranasal corticosteroids (79% and 55% prescriptions), followed by fixed-dose-combination of intranasal azelastine/fluticasone (19%). Polytherapy was the most common treatment strategy (59.6%). HCPs’ believe that the majority of the patients was adherent to treatment (88% with score > 7).This survey describes the therapeutic approach adopted by Italian physicians to cope with AR and shows that HCPs underestimated AR severity and had a non-realistic perception of patients’ adherence. These findings suggest that further efforts are required to improve AR clinical management in Italy. Allergic rhinitis (AR) is one of the most common disease affecting adults worldwide with increasing incidence and prevalence in almost all western countries –5. ThougDespite international and national are continuously reviewed and updated to optimize patient care guidelines  –19, AR cIn Italy, prevalence of AR has increased over the last 20 years from 16.8 to 25.8% , 29. A sThe present research investigated the current clinical practice patterns and prescribing behaviour of Italian healthcare professionals (HCPs) specialized in AR management. Allergologists, ear, nose and throat (ENT) specialists, and GPs were asked to retrospectively recover clinical data of real-life cases to assess: (1) prescribing behaviour based on patients’ characteristics; (2) AR therapeutic management; (3) opinions toward patients’ adherence.We carried out a survey among a total of 350 Italian HCPs treating patients suffering from AR. The survey sample included 100 allergologists, 100 ENT specialists, and 150 GPs. HCPs were randomly selected from a national database. Exclusion criteria were: < 5 years of clinical practice, < 5 AR patients visited over the last month, participation to another market research in the previous 6 months. Recruitment was carried out via mail and it was planned to equally represent physicians from all Italian geographical macro-regions in each specialty area. The interviews were performed in April 2019 and data were collected through Computer Assisted Web Interviewing (CAWI) lasting 20 min.The questionnaire used in the present research was designed based on findings from a systematic literature review and included two sections. The first section collected the HCPs’ socio-demographic data, such as age, gender, years of work experience, and number of monthly visited patients with AR. HCPs’ attitude toward relevant prescription drivers was likewise investigated  and symptoms-related discomfort experienced by patients and disease severity  when appropriate. Kruskal–Wallis One Way Analysis of Variance on Ranks followed by Dunn’s post hoc test were likewise used. Two Way ANOVA was used to investigate significance between specialty area and patient assignment to the different classes of AR severity. Tukey’s post hoc test was used for pairwise multicomparison procedure.Differences in variable distributions across specialists were tested with ΧA p < 0.05 was considered statistically significant. The data were analyzed using the statistics software SigmaPlot 11.0 .Relevant characteristics of the 350 respondents are described in Table All the prescription drivers presented through the questionnaire  were allergic only to pollens, 439 (15.6%) only to dust, 222 (7.9%) to other causes, 849 (30.1%) to more than one cause. About a quarter of the cases  suffered from concomitant asthma and the majority of these patients  took a specific drug for asthma treatment. Among asthmatic patients, 213 were only allergic to pollens, 117 only to dust, 36 only to other causes.As shown in Table From a physicians’ perspective, distribution of AR severity in the patients’ sample was: 1906 (67.5%) patients with moderate/severe AR and 917 32.4%) patients with mild AR  reported reduced productivity due to AR , while monotherapy was used in 41.4% of cases (1170 patients)  followed by fixed-dose combination of intranasal azelastine/fluticasone (Aze/flu) (543 prescriptions)  has good adherence to treatment, even in the cases of severe AR Fig. a. In HCPThe present survey investigated the current clinical practice scenario of AR management in Italy. In addition to provide an extensive description of Italian HCPs’ prescribing behaviour, this study discloses clinicians’ perspective about patients’ symptom discomfort and adherence.AR is characterized by substantial medical and social burden with high use of healthcare resources worldwide , 11, 34.In our survey, allergologist emerged as the main reference specialist for the disease in Italy, followed by ENTs. GPs visited more cases suffering from mild AR compared to both allergologists and ENTs. Prescription attitude was similar between HCPs. Attributes related to medication efficacy, safety, and patient adherence were considered more relevant prescription drivers than ease of use and cost-related items.Consistent with previous Italian studies , 32, theA remarkable finding of the present survey is that AR severity is underestimated by physicians, irrespective of the specialty area in which they operate. In fact, about half of the patients assigned to the mild class of severity actually experienced particularly bothersome symptoms. This observation is consistent with data reported by the European survey carried out in Germany, France, Italy, Spain, and UK, in which clinicians not only underestimated the severity of disease but also misdiagnosed the nature and discomfort of symptoms . As a coWith regard to HCPs’ opinions about patient adherence, our investigation disclosed that clinicians believe all the patients are compliant, even in the cases of severe AR. This perception does not reflect the real scenario of patients’ adherence in the AR settings. In fact, it is widely accepted that adherence in AR patients is very low , 47, 48.According to the interviewed physicians, the main cause of low compliance was relief of AR symptoms, followed by cost-related issues. Lack of efficacy, adverse effects, treatment duration, and costs are generally associated with lower compliance . PatientAR still represents a significant health problem because of the high burden of symptoms and the significant impact on patients’ QoL. The various available clinical guidelines state that accurate diagnosis, thorough patient evaluation, and adequate follow-up monitoring are a prerequisite to ensure optimal patient care.The present research showed severity of AR symptoms is underestimated by Italian physicians, regardless of the specialty area in which they operate. This could lead to inadequate control of the disease. In addition, HCPs are not fully aware of the poor adherence to treatment.These findings suggest that further efforts should be made to promote physicians’ adherence to clinical guidelines in order to improve AR management in Italy. Design of educational interventions for both GPs and specialists could improve characterization of the disease, help clinicians in the selection of the best treatment option, and promote a better patient-physician communication on the nature, severity, and impact of symptoms.Additional file 1. Supplementary methods and results.


Mechanical failure (MF) following adult spinal deformity (ASD) surgery is a severe complication and often requires revision surgery. Predicting a patient’s risk of MF is difficult, despite several potential risk factors that have been reported. The purpose of this study was to establish risk stratification model for predicting the MF based on demographic, and radiographic data. This is a multicenter retrospective review of the risk stratification for MF and included 321 surgically treated ASD patients . The analyzed variables were recorded for at least 2 yr and included age, gender, BMI, BMD, smoking status, frailty, fusion level, revision surgery, PSO, LIF, previous surgery, spinal alignment, GAP score, Schwab-SRS type, and rod materials. Multivariate logistic regression analyses were performed to identify the independent risk factors for MF. Each risk factor was assigned a value based on its regression coefficient, and the values of all risk factors were summed to obtain the PRISM score (range 0–12). We used an 8:2 ratio to split the data into a training and a testing cohort to establish and validate the model. MF developed in 41% (n = 104) of the training subjects. Multivariate analysis revealed that BMI, BMD, PT, and frailty were independent risk factors for MF . The MF rate increased with and correlated well with the risk grade as shown by ROC curve (AUC of 0.81 [95% CI 0.76–0.86]). The discriminative ability of the score in the testing cohort was also good (AUC of 0.86 ([95% CI 0.77–0.95]). We successfully developed an MF-predicting model from individual baseline parameters. This model can predict a patient’s risk of MF and will help surgeons adjust treatment strategies to mitigate the risk of MF. Various types of symptomatic and asymptomatic MF can be developed following ASD surgery  The postoperative MF rates for ASD have been reported to be as high as 50%17. Yilgor et al. have described that postoperative global alignment and proportion (GAP) were significantly correlated with the MF16. Theologis et al. reported that MF increased the treatment cost by more than double in ASD surgery17. Several previous studies have described the poor prognosis of patients who developed neurological deficits following MF15. Various risk factors for MF have been reported, including age, spinal misalignment requiring a large correction, osteoporosis, and the application of pedicle subtraction osteotomy (PSO)18. However, it is still difficult to prevent or minimize the risk of complications of individuals following ASD surgery.Mechanical failure (MF) following surgery for adult spinal deformity (ASD) is a severe postoperative complication and often requires planned and unplanned revision surgeryThis study aimed to establish ASD-specific risk stratification model for predicting the risk of MF using the individual’s demographic and radiographic, and surgical description data.This study was approved by the institutional review board at our institutions (Keio University School of Medicine Ethics Review Committee), and all subjects consented and agreed with their inclusion. We attest that the oral and written informed consents were obtained from all these patients. The all methods were performed in accordance with the relevant guidelines and regulations.19.We retrospectively reviewed charts and radiographs for 321 consecutive patients who underwent surgery for ASD in four academic hospitals between 2009 and 2016. For this study, we used the multicentered database established in a previous study and added 86 new patients who reached a 2-year postoperative follow-up durationSubjects were at least 20 years old at the index surgery and had a spinal deformity defined by a Cobb angle ≥ 20°, a C7 sagittal vertical axis (C7SVA) ≥ 5 cm, or pelvic tilt (PT) ≥ 25°. We included patients with at least 5 fused vertebrae, segmental instrumentation and fusion from the upper-instrumented vertebra (UIV) to the LIV (lower-instrumented vertebra), and complete 2-year follow-up data. Patients were excluded if they lacked appropriate radiographs or had multi-rod constructs, posterior tethering at the UIV + 1 vertebra, or syndromic, neuromuscular, or other pathological conditions.23. We collected the following surgical data: the SRS-Schwab ASD classification, GAP score, application of three column osteotomies, lateral lumbar interbody fusion (LIF), UIV and LIV levels, number of fused vertebrae, number of cross-connectors, material of the rods, estimated blood loss, and time of surgery. Radiographic data obtained at baseline and at the 6-week and 2-year follow-up, included the following measurements: Cobb angle, C7SVA, T4-T12, lumbar lordosis (LL), sacral slope, PT, pelvic incidence (PI), T1 pelvic angle (TPA), relative pelvic version (RPV), relative lumbar lordosis (RLL), lordosis distribution index (LDI) and relative spinopelvic alignment (RSA). As a surrogate for HRQOL, we used the Scoliosis Research Society-22r questionnaire (SRS22r) results at baseline and at the 2-year follow-up.We collected demographic and clinical data for each patient, including age, gender, body mass index (BMI), bone mineral density (BMD), smoking status, history of joint arthroplasty (hip), and spine surgery. Frailty and comorbidities were assessed using the modified frailty index (mFI) and the Charlson comorbidity index (CCI)Of 332 candidates, 321 subjects had complete demographic and radiographic data that sufficiently captured any instances of postoperative MF and were thus included in the study cohort. We split patient samples into a training and testing cohort at an 8:2 ratio. The remaining 11 candidates were lost during follow-up, including 4 candidates who died for reasons unrelated to the surgery and were excluded from the cohort.According to the previous literature, we included all MFs found on the radiographs that developed within 2 years of the operation .2, 18.5–25 kg/m2 >25 kg/m2; BMD T-score ≤ −1.5 or > −1.5; frailty: robust (mFI: 0), prefrail (0.09–0.21), or frail (≥ 0.27); UIV T1-T6 or T9-T11; LIV L5 and above or the pelvis; Cobb angle <70° or> 70°; C7SVA < 40 mm, 40–95 mm, or> 95 mm; PT < 20°, 20°–30°, or > 30°; PI-LL < 10°, 10°–20° or, >20°.Subjects were categorized into two groups: those who had any MF within 2 years of the operation and those who were free of MF. We investigated the relationships between patient demographics, spinal alignment, surgical factors, and the development of complications by univariate and multivariate logistic regression analysis using the data of the training cohort . We created categories based on clinical importance and on the results of unpaired t-tests and Tukey’s HSD test or the Wilcoxon ranked test where appropriate, as follows: age ≤ 60 years or > 60 years; BMI < 18.5 kg/mWe calculated the overall summary statistics, including the means and standard deviations for continuous variables and frequencies and percentages for categorical variables. After descriptive analysis, we analyzed the associations between potential risk factors and MF by univariate comparisons. We then created a multivariate binary logistic regression model to evaluate the adjusted associations of each potential explanatory variable and to predict the likelihood of developing MF. Clinically relevant variables and variables with a univariate significance level < 0.05 were included in the multivariate logistic regression analysis.Based on the predictors obtained from multivariate analysis, we designed a simplified, risk-stratification algorithm (PRISM) to provide a score that can be used to predict the incidence of MF. We included 6 variables in our risk-stratification model. We first established values for each risk indicator by rounding the β regression coefficient obtained in the univariate analysis to the nearest whole integer (0–3). Next, the values for all applicable risk indicators were added together with age and LIV level to establish the PRISM score (0–12). We evaluated the discriminative ability of the PRISM score based on the area under the receiver operating characteristic curve (AUROC). Linear regression analysis and the Cuzick test were performed to analyze whether there is a trend between the PRISM score and the incidence of MF. The PRISM score was used to stratify patient risk into low risk (0–1), moderate risk (2–4), high risk (5–8), and very-high risk (9–12).The PRISM model was applied to 64 testing samples that were not used for model development. The discriminative ability of PRISM was evaluated using AUROC analysis, linear regression algorithm, and the trend test.25. All analyses were performed using the Statistical Package for the Social Sciences .Differences between the MF and MF-free groups were compared by unpaired t-test, chi-square test, Tukey’s HSD test, and Fisher’s exact test where appropriate. Potential risk variables were analyzed by univariate and multivariate logistic regression. A correlation of the distribution of the observed MF rate for each PRISM score was created with a linear regression algorithm that best fit the data points with a 95% CI. A p value less than 0.05 with a CI of 95% was considered statistically significantAmong 257 training samples, MF developed in 40.5% (n = 104) of the patient cohort. The most common MF was PJK , and the second common was RF . Thirty-nine (38%) patients developed more than two MFs and 33 of the MF group patients (32%) required unplanned additional surgeries to treat the MFs.Patients who developed MFs experienced significant improvements in HRQOL, as measured by SRS22r at the 2-year follow-up . The PRISM score was determined as the sum of the values of the risk variables Fig. . Thirty-2 = 0.866, AUROC 0.855 [95% CI 765-0.945], Figs The PRISM score also showed excellent accuracy for predicting the incidence of MF, with an AUROC of 0.812 (95% CI 763-0.864, Fig. 15. In this study, MF developed in 40.5% of patients following ASD surgery. Among them, 39% of patients in the MF group developed multiple MFs during follow-up, and 30% of patients in the MF group required unplanned reoperation. Crawford et al. described that 24% of patients required an unplanned reoperation following ASD surgery, and the most common indication for reoperation was RF1. Inoue et al. described that the most frequent type of MF associated with reoperation was PJF25. In the present study, approximately 36% of RFs developed 3 years or longer after surgery, and 70% of them were not associated with either significant alteration in HRQOL or progressive deformity. Following the previous literature, the clinical outcomes of patients who developed MF were inferior to those of MF-free patients at 2 years after surgery. Soroceanu et al.26 described that MF significantly affected HRQOLs in 245 consecutive ASD surgeries. Lertudomphonwanit also described that the MF group had less overall improvement in HRQOLs than did the MF free group2. Recently, several cost-utility analyses of the surgical treatment for ASD have been performed28. Yagi et al. described that revision surgery for ASD increased the 2-year total cost by approximately 30% and significantly decreased the cost-effectiveness of the surgery27. Safaee et al. also described the significant alteration in cost-effectiveness of ASD surgery for those who required revision surgery28. Taken together, to predict the risk of MF and to reduce this common but significant surgical complication, it is essential to mitigate the risk of surgical complications and to improve the outcome of surgical treatment of ASD surgery.Mechanical failure is the most common surgical complication after ASD surgery18. One can argue that MF includes various implant-related complications, and therefore, the risk analysis should be oriented to each type of MF. However, there is an overlap among the risk of each type of MF. Yagi et al. described BMD, age, a large amount of sagittal alignment correction, and pelvic fusion as independent risk factors for PJF15. On the other hand, Smith et al. described these factors as independent risk factors for RF. In the present study, 38% of the MF group patients actually developed 2 or more types of MFs during follow-up30. This higher incidence of the development of multiple MFs in the same patient observed in the present study strongly supports the presence of common risk factors among the various types of MFs.Several potential risk factors for developing MF have been reported and confirmed in the previous literatureIn the present study, we established a mechanical failure predictive model based on individual demographics, baseline spinal alignment, and surgical descriptive data. The advantages of the model include the feasibility of the scoring system. This scoring system consists only of preoperative values and therefore can be fully assessed before surgery. The model also showed good accuracy for predicting the incidence of MF in both the training and testing cohorts, with an AUC of 0.81 in the training subjects and of 0.86 in the testing subjects.31. Therefore, either adjustment of BMD index or addition of race index may be necessary to further improve the accuracy of PRISM in the other different populations. Further analyses including different patient populations are necessary to validate the predictive power of our model for MF following ASD surgery. Despite these limitations, the present study clearly showed the good predictive probability of this newly created model, which is based on demographic, radiographic, and surgical description data, for predicting MF following ASD surgery.This study was limited by its retrospective design and the lack of external validation, which precludes drawing firm conclusions about our model’s predictive power for MF. However, we enrolled consecutive patients from a prospective database and analyzed the patients retrospectively, which is the most common method for investigating how a factor affects outcomes and complications in clinical research when randomized controlled trials are not possible. Moreover, MF is a radiographic complication and can therefore be retrospectively corrected from the periodical radiographs. In the present study, we enrolled patients from 7 surgeons in 3 academic hospitals in an East Asian country, so the patients were mostly Asian. Therefore, our results cannot necessarily be extrapolated to all other hospital settings. It is widely accepted that BMD is different between racesThe newly established risk-stratification scoring model can predicted MF following ASD surgery using individual demographics and radiographic parameters as well as surgical description data that would normally be collected routinely when considering surgical treatment for a patient with ASD. This model can help surgeons identify patients with a high risk of MF and treat modifiable risk variables to mitigate the risk of MF following ASD surgery.SUPPLEMENTAry Information.


Ircinia campana, a common Caribbean sponge subject to mass mortalities and disease. Microsatellites were used to genotype 440 individuals from 19 sites throughout the Greater Caribbean. We found strong genetic structure across the region, and significant isolation by distance across the Lesser Antilles, highlighting the influence of limited larval dispersal. We also observed spatial genetic structure patterns congruent with oceanography. This includes evidence of connectivity between sponges in the Florida Keys and the southeast coast of the United States (>700 km away) where the oceanographic environment is dominated by the strong Florida Current. Conversely, the population in southern Belize was strongly differentiated from all other sites, consistent with the presence of dispersal-limiting oceanographic features, including the Gulf of Honduras gyre. At smaller spatial scales (<100 km), sites showed heterogeneous patterns of low-level but significant genetic differentiation (chaotic genetic patchiness), indicative of temporal variability in recruitment or local selective pressures. Genetic diversity was similar across sites, but there was evidence of a genetic bottleneck at one site in Florida where past mass mortalities have occurred. These findings underscore the relationship between regional oceanography and weak larval dispersal in explaining population genetic patterns, and could inform conservation management of the species.Understanding population genetic structure can help us to infer dispersal patterns, predict population resilience and design effective management strategies. For sessile species with limited dispersal, this is especially pertinent because genetic diversity and connectivity are key aspects of their resilience to environmental stressors. Here, we describe the population structure of  The spatial distribution of genetic diversity is influenced by both ecological and evolutionary processes, and can be used to infer a number of important characteristics of species, including dispersal, recruitment and gene flow among populations (connectivity). Understanding these processes can help in ecosystem management and conservation Baums . In addiIn Greater Caribbean marine ecosystems, sponges are abundant, diverse and serve important ecological functions, including cycling of organic material and habitat provisioning , a common species in coral reef and hard-bottom habitats. The reproduction and larval biology of I. campana has not yet been described; however, other Ircinia species are viviparous, with no true asexual reproduction (through budding or gemmules), and the vase-shaped morphology of I. campana is not susceptible to fragmentation during storms. This species is prone to disease outbreaks, and has suffered a number of mass mortality events, the most extensive having occurred in the Florida Keys  have previously been affected by mass mortalities associated with cyanobacterial blooms. We cut small fragments of tissue (~1.5 cm3) and preserved them in 95% ethanol soon after surfacing. Ethanol was replaced after 24 h to avoid dilution with the seawater held in the sponge tissue.We sampled 10–41 We dissected samples under a stereomicroscope to remove macroinvertebrates from the sponge tissue, and extracted DNA using the DNeasy® Blood and Tissue Kit (Qiagen). We genotyped the samples for 10 microsatellite loci, as described in Griffiths et al. . Brieflyp.adjust function in R 3.4.3  calculations), the full ten-loci dataset was used. In all other analyses, Icam34 and Icam10 were excluded, yielding an eight-loci dataset.We tested linkage disequilibrium between loci using Genepop on the Web v4.2 (Raymond and Rousset d Estoup . Followi01 Table . ConsequHO) and Nei’s gene diversity (HS) (expected heterozygosity) for each sampling site using GenoDive v2.0b23  cycles and 50,000 burn-in cycles. We ran the model using all combinations of parameters for possible null allele causes , and used Bayesian deviance information criterion (DIC) to infer which parameters contributed more to the observed data.We calculated probability of deviation from Hardy–Weinberg equilibrium (HWE), observed heterozygosity (HS in separate models (eight-loci datasets), and ran the models using the R package ‘lme4’  hereafter), and tested significance using 50,000 permutations (with B–Y correction applied for multiple tests). We also calculated FST between population pairs for all ten loci with ENA correction for null alleles in FreeNA (referred to as FST(10) hereafter). We tested correlation between matrices of FST(8), FST(10) and D, using Mantel tests in the ‘ade4’ package in R with 9999 permutations.The traditional measure of subpopulation differentiation, igh Jost . Becauseigh Jost , we alsoion Jost . We calcD.To visualise genetic distance relationships among sites, we carried out principal coordinate analysis (PCoA) in GenAlEx 6.503 /1–FST(10) and D/1–D) and the logarithm of oceanographic distances with Mantel tests in ‘ade4’ in R, using 9999 permutations. We calculated least-cost oceanographic distances among sites  using ‘marmap’ in R (Pante and Simon-Bouhet We tested for the presence of genetic isolation-by-distance (IBD) patterns in the data by testing the correlation between pairwise matrices of linearised genetic distances (K) and individual assignment probabilities to those clusters, using the eight-loci dataset. We first ran the model using the uncorrelated allele frequencies, spatial and null allele models with 1,000,000 iterations, 100 thinning and 500 burn-in. According to the authors’ advice, we set the maximum number of nuclei to 1320 (3 × sample size) and the maximum rate of the Poisson process to 440 (1 × sample size), and the spatial uncertainty on coordinates to 0.0005. We carried out ten independent runs of K from 1 to 19, and checked that clusters were consistent among runs. We then selected the run with the highest posterior probability to estimate allele frequencies and cluster locations to use subsequently in the admixture model. We ran the admixture model using the same parameters as above, and extracted the Q matrix of individual probability assignments to each cluster to build a bar plot in Distruct  . Two identical multilocus genotypes  were present in the dataset , one of which was removed for subsequent analyses. Average null allele frequencies were high at many loci, overall ranging from <0.001 (Icam32) to 0.323 (Icam34) (Table All loci were in linkage equilibrium after B–Y correction (4) Table . Loci we4) Table .p < 0.05) at a number of loci and sites following the correction for multiple tests  to 0.565 (Panama C) within sites, and HS ranged from 0.528 (Gray’s Reef) to 0.761 (Mayreau) . Rarefied allelic richness per site ranged from 3.258 ± 0.552 SE  to 4.667 ± 0.589 SE (Mayreau) . However, post hoc Tukey tests revealed that only three pairs of sites were significantly different: allelic richness was significantly higher at St. Lucia than at Turneffe Atoll , at Mayreau than at Turneffe Atoll  and at Mayreau than at Waltz Key . All other site-by-site comparisons were not significant (p > 0.05), although three comparisons were close to significance . Rarefied private allelic richness ranged from 0.237 ± 0.107  to 1.302 ± 0.432 (St. Lucia) (Table u) Table . Site haa) Table .p = 0.014), indicative of a genetic bottleneck.Significant heterozygosity excess with respect to allelic richness was detected only at Bamboo Key (FST(10) reaching 0.233 (between Gray’s Reef and Panama 1) and D reaching 0.598 (between Gray’s Reef and Sapodilla Cayes) (Tables FST(10) and FST(8): r = 0.921, p < 0.001; FST(8) and D: r = 0.908, p < 0.001; FST(10) and D: r = 0.825, p < 0.001).Our analyses showed strong population structure across the region, with ) Tables  and S6. FST(10)r = 0.793, p = 0.001; D: r = 0.688, p < 0.001) : p = 0.483; D: p = 0.476)  Fig.  but not 76) Fig. .Fig. 2GeGeneland analysis of the whole dataset identified four genetic clusters Fig. , with fuThe DAPC showed a clear separation of the Sapodilla Cayes from all other sites upon analysis of the full dataset Fig. . In the D among sites, the second axis represented 21.02% and the third axis represented 12.48%, giving a total of 59.12% over the three axes. The first axis separated the USA sites from the rest of the sites, while the second axis clearly separated a St. Vincent, Mayreau and Bequia cluster .Both HWE deviations and null alleles are common in sponge microsatellite studies , an area subject to highly retentive oceanographic conditions  is unexpected, given the genetic and geographic distances among these locations, and the absence of specific water circulation patterns that might cause such a grouping. However, when analyses were repeated including only these sites, the sites divided into three separate clusters. This demonstrates the utility of repeating analyses on multisite clusters to uncover further patterns of population structure that are not revealed in the overall dataset analysis . IBD is driven by distance-limited dispersal Wright , which iFST ranged between 0.006 and 0.072), and the sites formed a single cluster in Geneland, PCoA and DAPC analyses. This suggests that larvae disperse across the area with sufficient regularity to maintain gene flow . This result is interesting given the short larval duration and low dispersal capacity predicted for sponges, but concurs with other studies that show higher-than-expected levels of connectivity and dispersal  considering their proximity (15 km). In addition, the DAPC and PCoA analyses highlighted genetic separation between the sites. Diamond Rock (MAR2) is a small island located 3 km off the Martinique coast. Both the island and the channel separating it from the mainland are locally known to experience strong currents (pers. comm. G. Tollu), and early modelling of water circulation suggests that the area may be influenced by a small gyre off the southern coast of Martinique , but a bottleneck signature was not detected here. This could be because any loss in genetic diversity was rapidly regained through recruitment and gene flow from other areas. Indeed, the Long Key site is dominated by long-shore currents, whereas the Bamboo Key site sits within a bay subject to a local gyre. Alternatively, it is possible that the Long Key result is a false negative, as heterozygosity excess tests are sensitive to mutation model selection and sample-size limitations . However, we did observe a disease-like condition in individuals harbouring necrosis of various stages in Guadeloupe and Bequia during sampling for this study, and on other occasions in Martinique (pers. obs. T. Pérez and S. Griffiths). Indeed, disease outbreaks and mass mortalities have been reported multiple times in Understanding the scale and magnitude of connectivity among populations is important for the management and conservation of marine ecosystems (Almany et al. I. campana populations; this should be maintained in restored sites through the use of a large number of donor sponges, rather than extensive fragmentation of few sponges.Our results also provide insight for management of mass mortality-affected sites in Florida. Restoration through fragmenting and transplanting healthy sponges has been successfully used to repopulate barren areas (Butler et al. Supplementary Information


Laparoscopy has been widely used for patients with early-stage epithelial ovarian cancer (eEOC). However, there is limited evidence regarding whether survival outcomes of laparoscopy are equivalent to those of laparotomy among patients with eEOC. The result of survival outcomes of laparoscopy is still controversial. The aim of this meta-analysis is to analyze the survival outcomes of laparoscopy versus laparotomy in the treatment of eEOC.Clinicaltrials.gov were searched for studies from January 1994 to January 2021. Studies comparing the efficacy and safety of laparoscopy versus laparotomy for patients with eEOC were assessed for eligibility. Only studies including outcomes of overall survival (OS) were enrolled. The meta-analysis was performed using Stata software (Version 12.0) and Review Manager (Version 5.2).According to the keywords, Pubmed, Embase, Cochrane Library and P = 0.446), progression-free survival (PFS)  and upstaging rate . But the recurrence rate of laparoscopic surgery was lower than that of laparotomic surgery .A total of 6 retrospective non-random studies were included in this meta-analysis. The pooled results indicated that there was no difference between two approaches for patients with eEOC in OS (HR = 0.6, Laparoscopy and laparotomy appear to provide comparable overall survival and progression-free survival outcomes for patients with eEOC. Further high-quality studies are needed to enhance this statement. Ovarian cancer is one of the most common malignant tumors in gynecology, and its five-year survival rate is only about 46% after diagnosis, which has the highest death rate in gynecologic tumors , 2. MoreClinicaltrials.gov. Additionally, we also searched relevant references for articles. All studies were assessed by two investigators independently and any difference was settled by discussion. Studies in all languages were included.The study was conducted according to the meta-analysis of observational studies in epidemiology (MOOSE) guidelines. We performed a literature search using the keyword “laparoscopy”, “laparoscopic”, “robotic”, “minimally invasive surgery”, “early-stage ovarian cancer”, “early-stage adnexal cancer”, “stage I ovarian cancer”, “stage II ovarian cancer” in various combination from January 1994 to January 2021 in PubMed, Embase, Cochrane Library and Articles comparing the survival outcomes of laparoscopy and laparotomy staging surgery with eEOC were considered appropriate for analysis. Studies were excluded via the following criteria: duplicate publications, abstracts, letters, case reports, reviews, single-arm studies and conference reports. Studies which did not focus on early-stage ovarian cancer were excluded. Studies involving other ovarian cancer types beyond EOC  were excluded. Studies involving laparoscopy surgery only for exploration not for therapeutic staging operation were excluded. Studies with insufficient data for estimating the HR and 95% CI were also excluded.Overall survival (4-5 years)  Progression-free survival (PFS) or disease-free survival (DFS) or recurrence-free survival (RFS) Recurrence rate (4-5 years) (rate of recurrence)Upstaging rate (rate of postoperative upstaging)The following data were extracted: baseline characteristics including age, BMI, stage of disease, how patients were found, reason for exclusion of participants, previous therapy and surgery, pre-operative preparation, level of training of surgeons, postoperative chemotherapy, follow-up, OS, PFS, upstaging rate, tumor rapture or spillage, methods of tumor extraction and port-site metastasis. The risk of bias in individual studies was assessed by Egger’s publication bias plot. Oxford center for evidence based medicine checklist for prognostic studies were used to evaluate the methodological quality.2) was adopted to quantify the effect of statistical heterogeneity. A value of 0% indicated no observed heterogeneity and a value more than 50% was considered substantial heterogeneity. If I2 > 50%, the random-effects model was adopted, otherwise, the fixed-effects model was used to pool the results. Review Manager (Version 5.2) was used to do the risk of bias graph and the risk of summary. A two-sided P < 0.05 was considered statistically significant.This meta-analysis was performed using Stata software (Version 12.0) and Review Manager (Version 5.2). The HR of the publications were obtained with Engauge Digitizer (Version 10.8). We used the Cochran Q test to evaluate the heterogeneity. Heterogeneity was used to evaluate the percentage of the variation in all studies. Because of inevitable clinical and methodologic diversity, inconsistency  ranged from 4.0% (2/50) to 15.4% (11/71) versus 6.8% (4/58) to 12.9% (4/31). However the whole tumor rupture or spillage rate was not mentioned in these studies. Number of pelvic-aortic lymph nodes dissected was 15–31 in the laparoscopy group and 13.5–61 in the laparotomy group respectively [The searching process was shown in Fig. Egger’s publication bias plot of the studies included in this meta-analysis was notably symmetrical indicating that there was no obvious bias in publication shown in Fig. 2 = 0.0%, P = 0.93 for heterogeneity, P = 0.446 shown in Fig. P > 0.05). While, according to Xiong et al.’s study, 5-year overall survival rates were 86.7% versus 86.8% in laparoscopic groups and laparotomic groups, respectively (P = 0.874). Gallotta et al.’s study reported that 4-year OS rates were 92% in the laparoscopic group, 91% in the laparotomic group (P = 0.719). Merlier et al.’s study reported 5-year OS rates were 97.3% in the laparoscopic group, 79.8% in the laparotomic group. The other two studies did not mention accurate OS rate. However, Ditto et al.’s study reported after a mean (standard deviation) follow-up of 49.5 (64) versus 52.6 (81.8) months after laparoscopic and laparotomic surgery, there was no difference in survival outcomes. The similar results were indicated in Minig et al.’s study (the mean OS of 85.4 months versus 67 months in LPS and LPT (p > 0.05)).We analyzed the overall survival 4-5 years) of laparoscopy versus laparotomy for patients with eEOC in the 6 publications. The pooled results indicated that there was no difference in OS between two approaches . The accurate PFS rate of patients were not mention in the other two studies. Ditto et al.’s study reported that after a mean (standard deviation) follow-up of 49.5 (64) versus 52.6 (81.8) months after laparoscopic and laparotomic surgery, there was no differences in survival outcomes. Minig et al.’s study reported the similar results (the mean PFS of 73.6 months versus 64.8 months in LPS and LPT (P > 0.05)).Data from 4 publications were extracted to analyze the progression-free survival (two studies did not provide PFS data). The pooled results indicated that there was no difference in PFS between two groups . The pooled results indicated that recurrence rate in laparoscopic surgery was lower than that in laparotomic surgery . The pooled results indicated that there was no difference in upstaging rate between two groups  [Upstaging rate might be another factor which affected the outcome of OS and PFS. Firstly, intraoperative tumor rupture and spillage might be a major reason which affected the upstaging rate. The review by Tantitamit et al. concluded that the rate of intraperitoneal spillage among patients with ovarian cancer treating with laparoscopy was 1.3 to 37.5%. The main factor influenced intraperitoneal spillage might be the size of tumor. Larger tumors might be more likely to rupture . The stu= 1.000) . The stu= 1.000) . However= 1.000) . The cli= 1.000) . The proSecondly, more lesions can be found by adequate exploration and surgical excision during the operation which might affect the upstaging rate. The critical factor for management of ovarian cancer is primary surgery with complete excision of macroscopic and palpable lesions in the pelvis and abdomen. It has been thought that completion staging was technically difficult to be attainable via laparoscopy, nevertheless, with the superiority in optical magnification and refinement of laparoscopic techniques, laparoscopic surgery performed by expert surgeons can achieve a complete assessment and treatment equivalent to laparotomy . HoweverThe results indicated that there was no difference in 4-5 years OS, PFS and postoperative upstaging rate respectively between two surgical approaches for eEOC. However, recurrence rate in laparoscopic surgery was lower than that in laparotomic surgery. Sensitivity analysis of recurrence rate showed the study of Merlier et al. was the reason of heterogeneity . ExcludeThis meta-analysis reviewed clinical researches comparing the survival outcome of laparotomy and laparoscopy for patients with eEOC through January 2021. Our results are valuable for surgeons, given the comparable survival outcomes between two surgical approaches. The main limitation of our study is that the number of included studies is small relatively and all of the inclusive publications are retrospective in design. The reason of this is that there has been no prospective studies or RCTs published up to now about the prognosis in laparotomic surgery versus laparoscopic surgery for patients with eEOC. An ongoing RCT (NCT02686463) seeks to provide definitive comparison of outcome data between laparoscopic and laparotomic surgeries in eEOC patients. The result of this RCT might provide more convincing data. Additionally, eEOC tends to have a favorable prognosis with the 5-year survival rate after comprehensive surgical treatment reaching 90% [In conclusion, this meta-analysis indicated that laparoscopy and laparotomy appear to provide comparable survival outcomes, and laparoscopy might be an efficient and safe procedure for patients with eEOC. Further high-quality studies are needed, especially, randomized controlled trials (RCTs).


Chronic kidney disease (CKD) is a growing challenge in low- and middle-income countries, particularly in sub-Saharan Africa. There is insufficient population-based data on CKD in Nigeria that is required to estimate its true burden, and to design prevention and management strategies. The study aims to determine the prevalence of CKD and its risk factors in Nigeria.We studied 8 urban communities in Kwara State, North-Central zone of Nigeria. Blood pressure, fasting blood sugar, urinalysis, weight, height, waist circumference and hip circumference were obtained. Albuminuria and kidney length were measured by ultrasound while estimated glomerular filtration rate (eGFR) was derived from serum creatinine, using chronic disease epidemiology collaboration (CKD-EPI) equation. Associations of risk factors with CKD were determined by multivariate logistic regression and expressed as adjusted odds ratio (aOR) with corresponding 95% confidence intervals.2 and/or Proteinuria was 12%. Diabetes , obesity , proteinuria ; female sex ; and age  were the identified predictors of CKD.One thousand three hundred and fifty-three adults ≥18 years  with mean age of 44.3 ± 14.4 years, were screened. Mean kidney lengths were: right, 93.5 ± 7.0 cm and left, 93.4 ± 7.5 cm. The age-adjusted prevalence of hypertension was 24%; diabetes 4%; obesity 8.7%; albuminuria of > 30 mg/L 7%; and dipstick proteinuria 13%. The age-adjusted prevalence of CKD by estimated GFR < 60 ml/min/1.73mCKD and its risk factors are prevalent among middle-aged urban populations in North-Central Nigeria. It is common among women, fueled by diabetes, ageing, obesity, and albuminuria. These data add to existing regional studies of burden of CKD that may serve as template for a national prevention framework for CKD in Nigeria. One of the limitations of the study is that the participants were voluntary community dwellers and as such not representative for the community. The sample may thus have been subjected to selection bias possibly resulting in overestimation of CKD risk factors. Chronic kidney disease (CKD) is a significant health concern globally. The Global Burden of Disease (GBD) study ranked CKD the 19th leading cause of morbidity and death in 2013 ; The pooDespite the large population size of Nigeria with 180million people, little is known about the epidemiology of CKD in the general population. There is no national data on prevalence of CKD, and only few community-based studies were done in some regions of the country. A recent systematic review identified 7 population-based studies, 5 from the Southern part and 2 from the Northern part  previousThe aim of the current study was to estimate the prevalence of CKD and cardiovascular disease risk factors, and determine risk factors for CKD, among the adult population in Kwara State located within the North-Central geo-political zone of Nigeria.We conducted a cross-sectional study in eight urban communities in Kwara State located in North-Central zone of Nigeria. The study was conducted by the Ilorin Renal Study Group (IRSG) with the supports of the University of Ilorin Teaching Hospital, the local government authority and staff of the primary care hospital of the host community. The IRSG comprises adult and Paediatric Nephrologists, Nephrologists-in-training, Nephrology Nurses, Laboratory Scientists and Technicians, Radiologists, Urologists and Pathologists with interest in CKD care. They were responsible for administering questionnaires, physical measurements, and blood and urine collection for laboratory tests. The staff of the hospitals and health centers of the host communities were involved in the registration, physical measurements and data collection from the participants. The study was conducted in 8 urban communities. The study was undertaken as a community screening programme during world kidney days. The 8 communities were randomly selected by lottery within the 16 local governments that made up the Kwara State.The communities were capitals of local government areas (LGA) randomly selected from 16 that constitute Kwara State and they are: Adewole , Omu-Aran (Irepodun LGA), Oke-Oyi (Ilorin East LGA) Shao (Shao LGA) Offa (Offa LGA), Pake , Jebba (Jebba LGA), and Afon (Oyun LGA). The people are homogenous with predominant ethnic groups comprising Yoruba, Fulani and Igbo. Other tribes were Nupe and Baruba. Majority are civil servants, traders, artisan and students. The population of Kwara state is about 3 million. The programme was announced on the radio and through the community leaders. We obtained approval from the local government authority and the traditional heads of each community 12 weeks before the screening.The study population were healthy adults 18 years and older who are resident in the host community. The participants were voluntary individuals mobilized through the community heads and local government’s heads. Health education on kidney disease was delivered and Verbal informed consent was obtained from each participants.We excluded people with urinary tract infection and women that are menstruating which may produce false positive albuminuria and hematuria. We also excluded pregnant women which may yield physiological albuminuria.2). The waist circumference (WC) was measured with a non-elastic graduated tape at midpoint between the lower margin of the lowest palpable rib and the top of the iliac crest. Hip circumference (HC) was measured at the widest portion of the buttocks. We calculated waist-hip ratio (WHR) by WC (cm) / HC (cm). One sonologist performed ultrasonography of the kidney using Sonoscape Medical Digital Colour Doppler Ultrasound System (S30) with multiple frequency probes. Albuminuria was determined by HemoCue Albumin 201 point-of-care system  [.All participants filled in a questionnaire about demographic characteristics and medical history, and were physically examined. We measured blood pressure by mercury sphygmomanometer with standard cuff (25cmx12cm), on the right arm with participants in sitting position after 5 min rest. Two measurements were taken and the average was recoded. The weight was measured with a Seca weighing scale placed on a flat, hard surface with the participants wearing light clothing. The height was measured by a stadiometer with the participants standing without shoes. We calculated body mass index (BMI) by weight (kg)/height  . Fasting2 and/or albuminuria > 300 mg/g, hypertension as blood pressure ≥ 140/90 mmHg or use of antihypertensive drugs, diabetes as fasting plasma glucose > 7.0 mmol/L, and obesity as BMI ≥30 kg/m2 or waist-hip ratio > 0.85 in women and > 1.0 in men. Dipstick proteinuria was reported as ≥ + 1, and hematuria as ‘trace’ or ≥ + 1. Albuminuria was defined as > 30 mg/g, and anaemia by hemoglobin levels < 12 g/dl for women, and < 13 g/dl men.Estimated glomerular filtration rate (eGFR) was derived from chronic disease epidemiology collaboration (CKD-EPI) . Serum cThe data were analyzed by SPSS version 17 . The missing data was handled by multiple imputation method using Markov chain Monte Carlo (MCMC) method.p-value < 0.05 was chosen as significant level.Continuous variables that were normally distributed are expressed in means with standard deviation (SD), while those that were skewed are expressed in median with range. Categorical variables are expressed as percentages. Student t test was used to determine differences in the means of normally-distributed continuous variables and Chi-squared test for categorical variables. The prevalence of CKD and risk factors were adjusted for age and sex by direct standardization techniques, using the age and sex structure (stratification) of the 2006 population census of Nigeria . Partialp = 0.007). Women accounted for 56% (n = 758) of the participants. The prevalence of self-reported hypertension was 8.6%, and was higher in women (10%) than men (5.9%), p = 0.002. We observed a prevalence of hypertension of 20.6% with no difference between men and women (p = 0.457). Similarly, no difference in the prevalence of self-reported (1%) and observed (6%) diabetes was observed between men and women. Women presented with higher body mass index , and waist circumference  than men, while men had higher proteinuria , haemoglobin , and eGFR (106(75–156) versus 85(61–114) ml/min/1.73 m2, p = 0.031).Table p = 0.001. Stage 3 CKD accounted for the highest prevalence (9.5%) and was significantly higher in women (11.6%) than men (6.9%), p = 0.001.Prevalence was observed to increase with age from 10.5% at age < 30 years to 40-49 years (14.7%), and declined slightly to 11.7% at > 50 years, showing a similar trend in men and women. Albuminuria of ≥30 mg/dL was found in 7.1%, and was similar between men and women, p = 0.090. The prevalence of hypertension was 23.7%, diabetes 4.1% and are similar in men and women. Obesity was observed in 8.7% of the study population and was significantly higher in women (11.8%) than men (5.2%), p = 0.001.Table p = 0.042), had more often diabetes , wider hip circumference , higher median albuminuria (38.6(15.2–59.4) versus 30.9(13.2–55) mg/L, p = 0.042), and lower eGFR (44.8(32.3–54.9) versus 104.5(85.2–132.5) ml/min/1.73m2, p = 0.001. The figures were comparable between men and women. There was no difference in mean systolic blood pressure (p = 0.564), diastolic blood pressure (p = 0.543), prevalence of hypertension (p = 0.512), obesity (p = 0.266), and dipstick proteinuria (p = 0.591).Characteristics of participants with CKD compared with those without CKD are shown in Table r = − 0.171, p = 0.001), female sex , measured hypertension , diabetes , dipstick proteinuria , albuminuria , waist circumference , hip circumference , and waist-hip ratio .The correlation between demographic and clinical factors with eGFR is described in Table p = 0.001) was the most potent risk factor for CKD in the community followed by age , female sex, and central obesity defined by waist-hip ratio. Other traditional risk factors for CKD such as hypertension and obesity did not contribute to the logistic regression model. Among the markers of kidney damage assessed in the study, dipstick proteinuria  and quantitative albuminuria  were significantly associated with CKD.Independent risk factors for CKD determined by multiple logistic regressions are shown in Table This study estimated the prevalence of chronic kidney disease and its risk factors in urban populations of Kwara State in Nigeria. CKD, its risk factors and markers of kidney damage were prevalent among adults in Kwara State and occur in the younger population. CKD affected more women than men; age, female sex, diabetes, and obesity were the most pronounced risk factors for CKD.The prevalence of CKD of 12% in this study is similar to the adjusted figures reported by Ulasi et al. 11.4%) , and sig.4% , andPrevalence of CKD is further comparable to global and African figures , 4, 12 iThe discrepancies in the prevalence may be due to different equations used to derive estimated glomerular filtration rate (eGFR), study design and population. Some studies used Modification of Diet in Renal Disease (MDRD) or Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), others used Cochroft-Gault equation which consistently overestimates CKD in the general population. Further, many studies employed a cross sectional design with a single measure of eGFR.The high prevalence of CKD in SSA is due to many factors including a growing trend of non-communicable disease, prevalent use of nephrotoxic herbs and drugs, human immunodeficiency virus infection, and obesity. In addition, ethnicity and genetic factors such as inheritance of risk alleles of APOL1 may also contribute to the CKD risk. As observed in many previous studies in SSA, patients with CKD in this study are much younger than those in high-income countries, and this has implications for economic productivity of the sub-region.The higher prevalence of CKD we observed in women agrees with other studies in Nigeria and global analysis , 18–20. Herbal preparations and mercury containing cosmetic products which are nephrotoxic, are commonly used among women in Nigeria and Africa, and may add to the increased prevalence of CKD among women. Li et al.  reportedThe high prevalence of hypertension corroborates previous studies in Nigeria , 25. HypIn this study, the prevalence of diabetes is four-fold higher than self–reported, and has highest odds for CKD risk. We also found awareness rate for diabetes of 25%, perhaps underlining high CKD burden. A systematic review and meta-analytic studies revealed that in Nigeria, age-adjusted prevalence of diabetes increased from 2% in 1990 to 5.7% in 2015 with women having higher prevalence compared with men . DiabeteWe found prevalence of obesity of 8.7%; 5.2% in men, and 11.8% in women. A population study also showed that the obesity is higher in women  than men . In addition, the study of obesity reported that female sex was associated with higher risk for obesity  . The preWe found dipstick proteinuria in 12.9% of the study population, to be higher in men (15.3%) than women (11.1%), despite a higher CKD prevalence in women. No significant difference between participants with CKD and without CKD was observed. Possible explanations include coexisting factors promoting progression of CKD in women that are not measured in this study. For example, use of bleaching soaps and cream that contains mercury is common among women in Nigeria and SSA. We also observed albuminuria ≥30 mg in 7.1% of the study population, with similar proportion among the gender. Studies have consistently shown that albuminuria or proteinuria predicts end-stage kidney disease (ESKD), death and progression of CKD , 35. The2 in semi-urban communities in South-west Nigeria [Determinants of CKD identified in this study were: diabetes, increasing age, and abdominal obesity which are also risk factors for cardiovascular disease (CVD), in line with results from studies elsewhere , 36, 37. Nigeria . The pre Nigeria . FurtherThe finding that hypertension is not associated with CKD in this study is surprising because it is well established risk factor for CKD. However, our finding agree with report by Ulasi et al.  who alsoOur study provides estimated age- and sex-adjusted prevalence of CKD and its risk factors in adult urban populations in Kwara State, located within the North-Central zone of Nigeria. The strength of the study is the large sample size from multiple communities in previously understudied population. To the best of our knowledge, this study is the largest of the few population-based studies on CKD in Nigeria. Due to the relatively non-diversity in the socio-cultural and life-style of the people in the North-Central and the North generally, the findings may reflect CKD prevalence and risk factors within the region. Thus, it contributes significant proportion to the available data that may be used for health planning.The limitation of the study is that, we used a cross-sectional (survey) design, and a single creatinine measurement to estimate eGFR which may overestimate the prevalence of CKD. Major guidelines have recommended measuring serum creatinine twice, 3 months apart to validate its level for eGFR estimation. Several studies including analysis of population-based data observed that majority of surveys did not repeat eGFR estimation after 3 months to confirm CKD. However, we included albuminuria with reduced eGFR to define CKD to reduce overestimation of CKD using only eGFR. The participants in this study were voluntary community dwellers and as such not representative for the community and the sample may have been subjected to selection bias possibly resulting in overestimation of CKD risk factors.This multi-community study reveals that CKD and its risk factors are prevalent among middle age healthy urban population in North-Central Nigeria. CKD is common among women, fueled by diabetes, aging, obesity, and albuminuria. These data add to existing regional studies on burden of CKD, and may provide template for planning national prevention framework for CKD. However, a more nationally-representative study is required to understand the etiologies of CKD among young adults especially women in Nigeria. The role of pregnancy-associated kidney disease, exposure to mercury containing cosmetic products, use of herbal remedy and CKD of unknown cause should be explored, and for an improved prevalence estimate of CKD in Nigeria.


A 21-day postoperative rehabilitation program effectively reduces oxidative processes, which helps the patients after total hip or knee replacement in a successful recovery.Imbalance in prooxidant-antioxidant equilibrium plays an important role in the progression of osteoarthritis (OA). Postoperative rehabilitation significantly improves the functional activity of patients with OA. We aimed to assess the effect of the general 21-day postoperative rehabilitation on the oxidative stress markers in patients after total hip arthroplasty or knee replacement. Patients (n =41) started individually designed postoperative rehabilitation ca. 90 days after endoprosthesis implantation. We used the six-minute walk test (6MWT) to quantify the changes in their exercise capacity. We analyzed the oxidative stress markers: total antioxidant capacity (TAC), total superoxide dismutase (SOD), Cu-Zn-superoxide dismutase (CuZnSOD) and ceruloplasmin (Cp) activity, malondialdehyde (MDA) and lipofuscin (LPS) concentration in patients serum to asses changes in the oxidative stress intensity. We found that after 21-days postoperative rehabilitation program: the average distance walked by patients increased by 69 m; TAC increased by 0.20 ± 0.14 mmol/l; both SOD isoforms activities increased by 1.6 (±1.7) and 1.72 (±1.5) NU/ml, respectively; but Cp activity decreased by 1.8 (0.7-3.7) mg/dl. Also, we observed lower concentrations of lipid peroxidation markers: by 19.6 ± 24.4  Knee and hip osteoarthritis (OA) are frequent conditions in elder individuals, as osteoarthritis itself is one of the most common joint disorders in the world . Pain anOsteoarthritis is a multifactorial process of joint degeneration and various mechanisms may underlay its development . One of It is known that rehabilitation significantly improves functional activity and quality of life of patients with osteoarthritis. However, it remains mostly unknown how rehabilitation affects biochemical processes of the body, especially antioxidative processes at the cellular level. This study aimed to assess the effect of a general 21-day rehabilitation program on the oxidative stress markers in patients after total hip arthroplasty or knee replacement.The study was carried out according to the Declaration of Helsinki and the protocol was fully approved by the Ethics Committee of the Medical University of Silesia in Katowice . Every participant of the study received the description of the protocol and was informed about its benefits and possible risks and returned the written informed consent before the study started.Forty-one patients after total hip  or knee  replacement, aged 61.0 ± 8.1 years, were included in the study. Twenty-two of them were men and 19 were women  and on the initial examination day, they were, on average, 89.6 ± 9.7 days after the replacement surgery. Due to concomitant health conditions that occurred during the study, results of five patients were excluded from the oxidative stress markers analyses. Further details are presented in Upon the arrival to the outpatients' clinic, the resting electrocardiogram (ECG) and blood pressure measurement were recorded, the body mass and height measurements were taken for each patient. Also in each case, the clinical interview was carried out to exclude patients with inflammatory disorders, infections, renal or hepatic insufficiency, active coronary artery disease, diabetes, heart failure, hormonal replacement therapy or supplementation with antioxidants that might have occurred or taken place 3 months before the study.All patients underwent a 21-day general rehabilitation program that started ca. 90 days after knee or hip endoprosthesis implantation. Rehabilitation sessions were conducted daily for 21 days, starting between 8 : 00 and 8 : 45 am. The main components of general rehabilitation program were physiotherapy, daily living activities training and patient's education on nutrition. The individual rehabilitation programs consisted of aerobic walking (30-45 min), strength training 20-30 min), rotor/bicycle training (30-45 min) and a cool-down phase (15 min). The patients were advised to continue the learned exercises and pro-health behaviour over the course of the day to keep their physical fitness and biochemical parameters at the beneficial level [-30 min, Osteoarthritis severely reduces the patient's exercise capacity. To quantify the exercise capacity, clinical practitioners use the 6-minute walk test (6MWT) . In our 3; S-Monovette, SARSTEDT) and into tubes with a clot activator . The samples for serum analysis were centrifuged at 4000 rpm for 10 minutes at 4°C, and stored in –80°C. Plasma and serum samples were subsequently frozen and stored at −80°C until biochemical analyses could be performed.Blood samples were collected before the initial and after the final rehabilitation session. Blood samples (5 mL) from ulnar vein were collected in the morning, at 8 : 00 AM, before breakfast. Blood was collected to the standard blood tubes: with EDTA , copper-zinc-superoxide dismutase (CuZnSOD) and ceruloplasmin (Cp) concentration. Non-enzymatic antioxidant systems were analyzed by assessing total antioxidant capacity (TAC), lipofuscin (LPS) and malondialdehyde (MDA) concentration.TAC was measured using a commercial kit . The 2,2'-azino-di-(3-ethylbenzothiazoline sulphonate) (ABTS) was incubated with a peroxidase (metmyoglobin) and hydrogen peroxide to produce the radical cation ABTS+, which has a relatively stable blue-green color and can be measured at 600 nm. The suppression of the color was compared to the standard for TAC measurement assays (Trolox). The results are expressed as Trolox equivalent (mmol/l). The inter- and intra-assay coefficients of variations (CV) were 1.1% and 3.8%, respectively.SOD isoenzymes' activity was determined with the use of the spectrophotometric method by Oyanagui . KCN wasCeruloplasmin (Cp) concentration was measured using the p-phenylenediamine kinetic method by Richterich  and exprμmol/l).MDA concentration was measured using the spectrophotometric method  were 2.8% and 9.7%, respectively.LPS concentration was determined according to Tsuchida et al. . Serum wχ2 test was used. Statistical significance was set at a p <0.05 and all tests were two-tailed. Statistical analysis was performed using data analysis software system Statistica, version 13.3.0 .Distribution of variables was evaluated by the Shapiro-Wilk test and quantile-quantile plot. The interval data were expressed as a mean value ± standard deviation (M ± SD) in the case of normal data distribution or as a median ) in the case of skewed or non-normal data distribution. The t-Student's test for dependent variables or non-parametric Wilcoxon's test were used for data comparison. In the case of skewed data distribution, the logarithmic transformation was done before analysis. To assess the relationship between qualitative variables, the χ2 = 2.81, p =0.093, In our study groups we observed interesting statistical tendency. Hip arthritis was more frequent in male patients, while knee arthritis was more frequent in female patients, but those results were not statistically significant  kg on average and was the same as in the post-rehabilitation period (84.4 ± 11.6 kg) (p <0.001)  m, whereas after rehabilitation they were able to cover the distance of 497.8 (± 54.2) m. The increase in the results of 6MWT was statistically significant ( <0.001) .Since five patients were excluded from the study due to concomitant health conditions, the results of oxidative stress markers were obtained for 36 patients: 18 men and 18 women, aged 58.8 ± 8 years. 24 of them were after total hip (66.6%) and 12 of them were after knee (33.3%) replacement surgery performed 89 ± 2 days earlier.p <0.001; p <0.001; p <0.001; p < 0.001; We observed an increase in total antioxidant capacity (TAC) by about 0.20 ± 0.14 mmol/l (95% PU: 0.15-0.25) (μmol/l (95% PU: 11.4-27.9), in MDA concentration in blood of patients after a 21-day rehabilitation program , the activity of total superoxide dismutase (SOD), Zn-Cu-superoxide dismutase (ZnCuSOD) and ceruloplasmin (Cp) concentration, as well as the concentration of malondialdehyde (MDA) and lipofuscin (LPS) – the oxidative stress markers – in patients subjected to general rehabilitation after knee or hip endoprosthesis implantation. To the best of our knowledge, this is the first study designed to compare the oxidative stress markers before and after the general rehabilitation cycle. Here, we report a significant increase in TAC level, SOD and ZnCuSOD activities and simultaneous reduction in Cp, LPS and MDA plasma levels after the 21-day general rehabilitation program. The physical rehabilitation not only improved all oxidative stress parameters but also positively affected patients' general health, as indicated by glucose and lipids profiles and inflammation and blood clotting parameters. It also significantly improved patients' physical efficiency and exercise capacity determined by the 6-minute walk test (6MWT). Although the walked distance in 6MWT has increased after the rehabilitation process, the patients' body mass remained the same, as expected.Osteoarthritis affects patients' antioxidative and oxidative metabolism by significantly impairing antioxidant defense . A decreWe found that the 21-day rehabilitation program conducted after the endoprosthesis implantation surgery significantly enhanced total antioxidant capacity. Our results coincide with those obtained by Porter et al.  analyzinIn our study, 21-day general rehabilitation program resulted in increased superoxide dismutase (SOD) and its Cu-Zn isoform (CuZnSOD) activity. According to two independent studies, by Scott et al.  and OlszOur results show that the implementation of the rehabilitation program shortly after the surgery might lead to increase of total SOD activity. Due to the methodology of our research, we had limited insight into the postoperative period only, not into the dynamics of the change. Nevertheless, the 21-day general rehabilitation, tailored to the patient's abilities, designed and controlled by a physiotherapist, resulted in a significant increase both in total SOD and CuZnSOD activity, what was compatible with results obtained by other research groups.In this study, we analyzed the ceruloplasmin concentration as an oxidative stress marker in patients who underwent endoprosthesis surgery and post-operative rehabilitation due to osteoarthritis. According to El-Barbary et al. , high leDuring exacerbated physical exercises, oxygen uptake and energy demand increase rapidly, which leads to the intensification of mitochondrial energy metabolism and, as a result, promotes free radicals formation which, if not scavenged effectively by SOD, cause lipid peroxidation and its by-product, malondialdehyde (MDA), formation. One of the main mechanisms of osteoarthritis pathogenesis is oxidative stress promoted by enhanced free radical production and therefore, not surprisingly, increased MDA levels are observed in the serum of the patients suffering from this condition , 13. ManThis may be due to a fact, that long-term resistance training causes qualitative and quantitative changes in respiration processes of skeletal muscle mitochondria, increasing thus antioxidant capacity .In our study, we observed that MDA, the lipid peroxidation by-product, levels dropped down significantly in convalescents after the 21-day general rehabilitation. We conclude that this is the effect of the study design: the patients underwent regular, daily low-intensity physical exercises, without prolonged or acute bouts of exercise, that were individually tailored to their abilities. This might have changed the respiration processes in skeletal muscles at the mitochondrial level, as discussed above, and have increased patients' antioxidant capacity, manifested also by elevated TAC levels we observed in our study.Lipofuscin is a product of the unsaturated fatty acids oxidation and its formation is directly related to an increased concentration of oxidative stress markers. Free oxygen radicals damage mitochondria and other cellular organelles, leading eventually to the formation of non-biodegradable lipofuscin that is stored in lysosomes, hindering their phagocytic activity and ability to degrade not-efficient and damaged mitochondria. This phenomenon is inevitably associated with the aging process –54. To tWe can conclude that the 21-day postoperative general rehabilitation program has a significant impact on balancing oxidative processes and significant reduction of oxidative stress markers in patients with hip or knee replacement. Individually tailored, systematic physical effort is a crucial element of the postoperative protocol, which helps patients to recover effectively after the surgery by improving the redox balance.


Giant cell arteritis (GCA) may lead to vision loss. To what extent tocilizumab (TCZ) is able to prevent vision loss is unknown. The aim was to analyze the occurrence of vision loss in a large GCA cohort treated with TCZ.In this observational monocentric study, GCA patients treated with TCZ between the years 2010 and 2018 were studied. Demographic, clinical, and laboratory data were analyzed.p = 0.032), had a lower C-reactive protein (p = 0.002), and showed a negative association with MRA of the aorta (p = 0.006). Two patients (1.1%) developed vision loss, both at the initiation of TCZ treatment.A total of 186 patients were included ; 109 (59%) fulfilled the American College of Rheumatology (ACR) criteria, in 123 (66%) patients, large vessel vasculitis was diagnosed by magnetic resonance-angiography (MRA). Cumulative duration of TCZ treatment was 224 years, median treatment duration was 11.1 (IQR 5.6–17.9) months. Glucocorticoids (GC) were tapered over a median of 5.8 (IQR 3.0–8.5) months. At baseline, visual symptoms were present in 70 (38%) and vision loss in 21 (11%) patients. Patients with vision loss at baseline were older (Our data show a very low incidence of vision loss in TCZ-treated patient. The two cases of AION occurred at the initiation of therapy, they support the hypothesis that advanced, and established structural changes of arteries are key factors for this accident. Whether a shorter duration of concomitant GC treatment is risky regarding vision loss needs to be studied. Vision loss is a rare event during therapy with tocilizumabThe data suggest a comparable incidence for tocilizumab and for glucocorticoid therapyThe early events support the hypothesis that advanced structural changes with lumen narrowing contribute to the risk for vision lossGiant cell arteritis (GCA) is the most common vasculitis in Western populations at older age , 2. VisiThe rate of vision loss in patients with GCA seems to have decreased over the last decades, probably due to earlier diagnosis of GCA and prompt start of GC treatment . NeverthIL-6 plays a central role in the pathogenesis of GCA . AccordiTherefore, we analyzed the frequency of vision loss in a large cohort of patients treated with TCZ and evaluated potential risk factors for vision loss.Data of 186 patients with GCA treated with TCZ between 1st January 2010 and 31st December 2018 at the Division of Rheumatology and Clinical Immunology of the University Hospital  Bern, Switzerland, were extracted from patient charts and entered in a REDCap database, which was prepared for this study and hosted at the Clinical Trial Unit (CTU) of the University of Bern, Switzerland. REDCap (Research Electronic Data Capture) is a secure, web-based software platform designed to support data capture for research studies. The patients fulfilled the criteria for GCA as defined in the two previously published RCTs , 13, i.eBaseline was defined as the time of diagnosis of GCA. Changes in vision loss were assessed by determination of best corrected visual acuity : Ameliorp value were displayed.All analyses were done using Stata 15 . We compared baseline characteristics of patients with and without vision loss prior to baseline, using the chi-squared test and the Wilcoxon rank-sum test as appropriate. We displayed the median durations of follow-up, tocilizumab, glucocorticoids, and concomitant treatments. The patient-years of tocilizumab treatment were also computed. Counts of visual impairment and vision loss during the follow-up were displayed. A number of relapses were also recorded and displayed regarding treatment time. We compared baseline characteristics of patients with and without relapses during follow-up, using the chi-squared test and the Wilcoxon rank-sum test as appropriate. Association between permanent vision loss at baseline and the following baseline characteristics: age, first CRP, jaw claudication, and abnormal MRA aorta status were shown in a table and estimated with a multivariate logistic regression model with all the variables presented in the table. Due to the low number of outcome, a limited number of covariates (maximum of 2 to 4) could be included in the model. PMR was not included, because its difference was not significant in the crude comparison between the two groups. We excluded fever from this model because there were no patients with fever and vision loss before baseline. Crude and adjusted odds ratio for all the other characteristics were computed, their 95%-confidence intervals and The cantonal ethical board of Bern, Switzerland, has approved this retrospective study. All patients gave their written general informed consent for the evaluation of their data.A total of 186 patients diagnosed with GCA were treated with GC and TCZ according to published RCTs , 13, i.ePatient characteristics at baseline are summarized in Table The median age at diagnosis was 71 years. 124 (67%) patients suffered from cranial symptoms, 90 (48%) from polymyalgic symptoms. In 135 patients, temporal artery biopsies were performed, which revealed histological features of GCA in 73 (54%) patients. In 123 (72%) out of 170 performed thoracic or thoracic-abdominal MRA an aortitis was found .A total of 21 patients (11%) had suffered from vision loss due to GCA already prior to baseline. Unilateral vision loss had occurred in 16 patients, whereas bilateral vision loss had occurred in 5 patients prior to baseline. At baseline, best corrected visual acuity  in the eye with acute vision loss was ≥ 0.5 in 11 eyes (42%), < 0.5 and ≥ 0.3 in 1 eye (4%), < 0.3 and ≥ 0.1 in 3 eyes (12%) and < 0.05 in 9 eyes (35%). The visual acuity at baseline of two patients was not exactly determined.In two patients vision loss occurred while under TCZ medication: The 69-years old male patient developed AION of the left eye (BCVA of 0.01) 2 weeks after first cranial symptoms occurred and 2 days after an amaurosis fugax. The immediate treatment consisted of pulses of 1 g methyl-prednisolone over 3 days, and, in addition, one TCZ infusion (8 mg/kg body weight iv). As the AION did not improve, he received three more pulses of 500 mg methyl-prednisolone and thereafter oral prednisolone (75 mg PDN = 1 mg/kg body weight). Two weeks later, while still on 75 mg PDN daily, he lost vision of the right eye too (BCVA of 0.003).The second patient, a woman of 78 years of age, participated in the GUSTO study . She received three pulses of 500 mg methyl-prednisolone followed by TCZ monotherapy. Fifteen days after GC-pulse therapy she suffered from an acute vision loss (BCVA of 0), which did not improve despite immediate treatment with three additional pulses of 1 g methyl-prednisolone followed by prednisone at a dose of 1 mg/kg bodyweight.p-value of adjusted OR 0.040), were older , and had more often cranial symptoms  and jaw claudication  and less often fever . There was a negative association of vision loss with LVV of the aorta on MRA  . Positive histology was more frequent in patients with vision loss compared to those without. The patients with vision loss had lower CRP levels at baseline  months. Visual acuity in the affected eyes remained stable in 15 eyes, decreased by ≥ 2 lines in 4 eyes, and increased by ≥ 2 lines in 8 eyes. One patient was lost to follow-up.p value for a Fisher’s exact test (1-sided): 0.224).We identified 67/186 (36%) patients who relapsed for the first time. 20/67 (30%) patients with a first relapse had at least a 2nd relapse. The data suggests that relapses occur at a comparable rate in patients who already had a relapse and in patients who did not yet have a relapse  patients with a first relapse relapsed before treatment with TCZ, 18/186 (9.7%) during treatment. Sixty-seven patients stopped TCZ during follow-up and 24/67 (35.8%) had a relapse after discontinuation of TCZ  suffered from vision loss in our cohort, which is in line with the reported rates in previous publications ranging from about 2–19% . In two Regarding GC, most studies showed a higher percentage of vision loss during treatment. One recent case-control study with 104 GCA-patients showed new ischemic events (AION) in 4% after initiation of treatment with GC . An abstRegarding evolution of vision loss, 15/28 eyes (54%) showed a stabilization of visual acuity while 8/28 eyes (29%) showed an improvement while treated with TCZ and GC. As the analysis of data was retrospective, these findings do not represent the whole cohort. Nevertheless, they argue for a stabilization of visual impairment during therapy, which is similar to an earlier study with GC treatment only. This prospective study of 34 biopsy-proven GCA with vision loss and treatment with GC showed a deterioration of visual acuity by 2 or more lines in 27% of the patients despite GC pulse treatment 1 g iv for 3 days, followed by 60–80 mg/d and tapering of GC .The relapse rate of GCA during TCZ treatment was lower in this cohort as compared to the follow-up data of the first RCT . This isWeaknesses of this study are the retrospective nature, the monocentric approach and the lack of a stringent protocol regarding GC-reduction. Furthermore, data regarding infection rate before and during or after TCZ treatment was not collected. Strengths are the sample size, the long-term data, and the meticulous data analysis of visual loss by an expert ophthalmologist.This is the first study focusing on the occurrence of vision loss in patients with GCA receiving TCZ treatment according to the protocol of the first two RCTs. Only 1 % of patients lost vision under TCZ treatment, a figure comparable to historic rates of 0.7–10% for standard GC therapy. Collectively, the data supports a central role of IL-6 and underlines the therapeutic benefit of TCZ in cranial GCA.