Reports on traumatic sciatic nerve injury associated with acetabular fracture are rare. In this study, we investigated the demographics of these injuries, their clinical characteristics, management, and factors potentially influencing neurological recovery.We retrospectively reviewed all patients diagnosed to have acetabular fracture at our trauma center between January 2014 and June 2021. Data on patient demographics, characteristics of sciatic nerve injury, neurological recovery, factors potentially influencing neurological recovery were analyzed.P = 0.046). Linear regression analysis showed that a nerve abnormality detected intraoperatively was a predictor of nerve recovery (P = 0.009). The mean recovery time was significantly longer for partial recovery than for complete recovery .Eighteen patients  met the diagnostic criteria. All these injuries involved the posterior wall or posterior column, and most patients had posterior dislocation of the hip joint. Four of the 19 sides with traumatic sciatic nerve injury involved the common peroneal nerve division and 15 involved both the common peroneal and tibial nerve divisions. Seventeen patients (18 sides) underwent intraoperative nerve exploration, which revealed abnormalities in 7 sides and no obvious abnormality in 11 sides. At the last follow-up, 10 sides (52.6%) had complete recovery and 9 (47.4%) had partial recovery; the difference was statistically significant between those with or without abnormal nerve damage during exploration (All the injuries in this series involved the posterior wall or posterior column, and most patients had posterior dislocation of the hip joint. Damage to the common peroneal nerve division was more severe than that to the tibial nerve division preoperatively. However, the degree of recovery of the common peroneal division was not worse than that of the tibial division. There was a relationship between the degree of neurological recovery and whether there was an abnormality at the time of intraoperative nerve exploration. Patients with partial recovery took longer to recover. Acetabular fracture is a severe intra-articular injury and is usually caused by high-energy trauma, such as a road traffic accident or a fall from height –4. Most The sciatic nerve is the largest and longest nerve in the body. It is the motor nerve of the hamstrings and calf and foot muscles and is an important sensory nerve of the calf and foot. The sensory and motor functions of almost all areas below the knee are innervated by the sciatic nerve , 8. ThisAcetabular fracture combined with sciatic nerve damage has an incidence of about 3.3–33% , 11, 12.This retrospective study reviewed the patient characteristics, clinical features, and management of traumatic sciatic nerve injury associated with acetabular fracture and evaluated the characteristics of neurological recovery from this nerve injury and the factors potentially influencing recovery.We retrospectively reviewed the patients with a diagnosis of acetabular fracture with traumatic sciatic nerve injury managed in our trauma center between January 2014 and June 2021. All patients were under the care of the Shandong Provincial Hospital Affiliated to Shandong First Medical University. All patients underwent procedures performed by a same surgical team. The study was approved by the Medical Ethical Committee at the authors’ institution. The present study conforms to the Declaration of Helsinki. All patients involved gave informed consent and all data were anonymized before the analysis to safeguard patient privacy.Information was collected on age, sex, mechanism of injury, Injury Severity Score (ISS), Abbreviated Injury Scale (AIS) score, associated injuries, type of fracture according to the Letournel-Judet classification system , whethert-tests were used for comparison between groups. The skewness and kurtosis, graphical methods, and nonparametric tests were used for normality tests, and the Mann Whitney test was used for nonparametric comparison of continuous variables. The categorical variable data that affected the likelihood of traumatic sciatic nerve injury were analyzed using Fisher’s exact test and the chi-square test. Linear regression analysis was used to determine whether the presence or absence of intraoperatively nerve damage predicted the degree of neurological recovery. A P-value of < 0.05 was considered statistically significant.All statistical analyses were performed using SPSS software version 24.0 . Data on parameters such as age, ISS, AIS, LSUHSC peripheral nerve score and recovery time were described using the mean ± standard deviation and n = 7, 8 sides) or iatrogenic sciatic nerve injury  were excluded, leaving 186 patients (194 sides) with acetabular fracture, 18 (9.7%) of whom sustained traumatic sciatic nerve injury, which was bilateral in one case  had complete clinical and radiographic data and were eligible for inclusion in the study. Type of fracture was described using the Letournel-Judet classification system. Patients with spinal cord injury . The average ISS was 32.5  and the average AIS score was 20.4 . The main cause of injury was a road traffic accident in 11 cases, a fall from height in 3, and a falling object in 2; 55.6% of the patients sustained hemorrhagic shock. Associated injuries were common, in particular those involving the chest and abdomen, as were fractures of a lower extremity  of the 19 traumatic sciatic nerve injuries involved the common peroneal nerve division and 15 (78.9%) involved both the common peroneal nerve division and the tibial nerve division. There were no cases of isolated tibial nerve division injury Table .Table 3MP = 0.040)  underwent nerve exploration using the Kocher-Langenbeck approach. The exception was 1 patient (1 side) who was not a candidate for surgery because of poor health status. Intraoperative observation showed that 3 sides were compressed by bone fragments, 2 were stretched, 2 were contused, and 11 showed no obvious abnormality (Table P = 0.000) . At the last follow-up, 10 sides (52.6%) with sciatic nerve injury had recovered completely, 9 sides 47.4%) had recovered partially, and no patient had no recovery. Nine of 19 common peroneal nerve division injuries showed partial recovery and 10 showed complete recovery; the complete recovery rate was 52.6%. Six of 15 tibial nerve division injuries recovered partially and 9 recovered completely, giving a complete recovery rate of 60%. The mean common peroneal nerve division score was 4.11 ± 1.20 and the mean tibial nerve division score was 4.42 ± 1.02. There were significant differences in the LSUHSC peripheral nerve score for the common peroneal nerve division, tibial nerve division, and common peroneal and tibial nerve divisions combined before surgery and at the last follow-up (7.4% had P > 0.05). However, there was a statistically significant difference in neurological recovery between those with and without an intraoperative sciatic nerve abnormality (P = 0.046) (Table P = 0.009) . However, patients in whom the injured nerve showed partial recovery had a significantly longer mean recovery time  , ultrasonography and EMG (electromyography) have not been used in these cases, which could be included in future study. Finally, our follow-up protocol did not fully cover factors such as rehabilitation exercises and physiotherapy, which may impact on the results.All traumatic sciatic nerve injuries associated with acetabular fractures involved the posterior wall or posterior column, and most patients had posterior dislocation of the hip joint. Damage to the common peroneal division was more severe than that to the tibial division before surgery. However, the degree of recovery of the common peroneal division was not worse than that of the tibial division; all patients had a recovery . The degree of neurological recovery was related to whether the nerve was found to be abnormal on intraoperative exploration. Patients with partial recovery required a longer recovery time.


Haemophilus influenzae type a (iHia) disease was detected in Alaska and Northern Canada in 2002 and 2000, respectively. From 2006 to 2017, 164 iHia cases  were reported. Rates of iHia disease per 100,000 persons were higher in Northern Canada compared to Alaska and were significantly higher in Indigenous  compared to non-Indigenous populations . Disease rates were highest in Indigenous children <2 years of age  and significantly higher than in non-Indigenous children <2 . The most common clinical presentation in children <5 years was meningitis of age and pneumonia in persons ≥5 years old. Most patients were hospitalised  and fatality was similar . MLST testing showed sequence types ST23 and ST576 in Northern Canada and ST576, ST23 and ST56 in Alaska. Alaska and Northern Canada have high rates of iHia disease. A vaccine is needed in these regions to protect young children.Invasive  Haemophilus influenzae is a bacterial pathogen that can cause a range of illnesses from respiratory infections to severe invasive diseases such as meningitis, pneumonia and septic arthritis [rthritis . The orgrthritis . Indigenrthritis . Incidenrthritis ,7. Conjurthritis . Collaborthritis ,10. HereStreptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis, and groups A and B streptococci [H. influenzae data began in 2000. Participants in Canada, Greenland, Finland, Norway, Sweden and the US Arctic submitted data on H. influenzae. This analysis used only data from Canada and the US Arctic; the other participating regions either had no or very few Hia cases  or did not provide serotype data . A previous publication described Hia in the North American Arctic during the years 2000–2005 [ICS is an international network of Arctic regions that share public health surveillance data on invasive bacterial diseases including ptococci . Partici000–2005 ; this maAnnualised incidence rates were calculated using population estimates for Northern Canada and Alaska obtained from Statistics Canada , and theH. influenzae disease was defined as illness in a resident of the surveillance area from whom H. influenzae was isolated or identified by polymerase chain reaction (PCR) from a normally sterile site sample including blood, cerebrospinal fluid, pleural fluid, peritoneal fluid, or joint fluid. Clinical manifestations of H. influenzae were determined by a review of the patient’s medical record.A case of invasive H. influenzae were forwarded to reference laboratories in Alaska and Northern Canada for species confirmation, serotyping and multilocus sequence typing (MLST). In Alaska, H. influenzae was confirmed by using Gram stain and factor X and V requirements ; a similar method is used in Canada . Capsular serotyping was performed by slide agglutination with Difco antisera  in ALASKA and  in Northern Canada (except the Laboratoire de Sante Publique in Quebec which used PCR). Serotype results in Alaska and Northern Canada were confirmed by PCR; PCR amplification of serotype-specific genes was done by using primers and probes as reported by Maaroufi, et al. [H. influenzae MLST website (http://haemophilus.mlst.net/).Isolates from cases of invasive , et al.  (Alaska), et al.   of invasive Hi were identified during 2006–2017; 412 isolates from these cases  were available for serotyping. Of these, 151 isolates (37%) were non-typeable ; the remaining 261 isolates were 164 (63%) Hia ; 43 (17%) Hib , 4 (2%) Hic , 4 (2%) Hid , 10 (4%) Hie  and 36 (14%) Hif  ).FigureAmong the 53 Alaska invasive Hia cases, 44 (83%) occurred in children <2 years of age, 5 (9%) occurred in children 2–4 years of age and the remaining 4 cases occurred in persons ranging from 8 to 77 years of age . Median In Alaska, the overall annualised crude invasive Hia incidence rate was 0.6 cases per 100,000 population . In AlasIn children under the age of 5 years, the most common clinical illnesses due to invasive Hia infection were meningitis , bacteraemia (26% Northern Canada) and pneumonia (25% Alaska). In individuals over the age of 5 years, pneumonia  and bacteraemia  were the most common clinical illnesses . Eighty-Subtyping of the Hia isolates by MLST showed that the Alaska isolates were comprised of three STs: ST576 , ST23  and ST56   and of tHia was described in the literature as early as 1931 ,20,21. CWhile secondary transmission of Hib was well known ,28, epidOur data show that invasive Hia continues to occur and be a concern in Arctic populations, particularly in Indigenous peoples. When compared to rates published in our previous collaborative analysis , overallThe severity of disease caused by Hia invasive infection is comparable to that seen in invasive Hib cases prior to the introduction of the Hib vaccine. Meningitis is the most common disease in children less than 5 years old with Hia infection in Alaska and Northern Canada, presenting in 45% and 27% of cases, respectively. Studies describing the epidemiology of invasive Hib disease in Alaska and Northern Canada pre-vaccine also report meningitis as the most common disease associated with the bacterial infection as well as case fatality rates that are similar to invasive Hia infections ,34. ViruH. influenzae disease prior to the introduction of Hib vaccine in Alaska and Northern Canada. Serotyping efforts at that time were primarily focused on identifying Hib cases; the non-b serotypes were often not specifically detected. This analysis does not include underlying condition data that might be helpful in identifying risk factors for invasive Hia disease. Although underlying condition data was collected during the time of this study, the data was not collected consistently.This study is limited by the lack of historical data available for non-b invasive This paper is an update to a previously published collaborative analysis of invasive Hia disease in Alaska and Northern Canada. Our data show that invasive Hia continues to cause morbidity and mortality among peoples of the North American Arctic, particularly Indigenous children. The severity of this bacterial infection as well as its increasing prevalence highlights the need for an Hia vaccine for use in Northern Canadian and Alaskan children.


A total dairy intake of ≥5 cups per day was also protective against high blood pressure (BP) , low HDL  and MS  compared to an intake of ≤1.4 cups per day. A high unfermented dairy intake (≥4 cups per day) was also associated with a lower risk of high body mass index (BMI)  compared to a low intake (≤1 cup per day), while a reduced risk of MS was observed with a fermented dairy intake of ≥2 cups per day  compared to an intake of ≤0.1 cup per day. In summary, increased consumption of dairy was associated with a lower risk of MS and components of CMR.There is conflicting evidence about the association between dairy products and cardiometabolic risk (CMR). We aimed to assess the association of total dairy intake with CMR factors and to investigate the association of unfermented and fermented dairy intake with CMR in Asian Indians who are known to have greater susceptibility to type 2 diabetes and cardiovascular diseases compared to white Europeans. The study comprised 1033 Asian Indian adults with normal glucose tolerance chosen from the Chennai Urban Rural Epidemiological Study (CURES). Dietary intake was assessed using a validated open-ended semi-quantitative food frequency questionnaire. Metabolic syndrome (MS) was diagnosed based on the new harmonising criteria using central obesity, dyslipidaemia [low high-density lipoprotein cholesterol (HDL) and increased serum triglycerides (TG)], hypertension and glucose intolerance. Increased consumption of dairy  was associated with a lower risk of high fasting plasma glucose (FPG) [hazards ratio (HR), 95% confidence interval (CI): 0.68, 0.48–0.96 for total dairy; 0.57, 0.34–0.94 for unfermented dairy; and 0.64, 0.46–0.90 for fermented dairy;  Asian Indians have been shown to have distinct biochemical and clinical characteristics that put them at risk of type 2 diabetes (T2D) and cardiovascular diseases (CVDs) ,2,3,4. TThe existence of an entity called MS is surrounded by controversies, partly due to variations in the definition of MS ,10,11,12Furthermore, consumption of dairy is high among Asian Indians ,27,28 whThe current study consisted of 1033 adults with normal glucose tolerance chosen from the Chennai Urban Rural Epidemiological Study (CURES), and details of the study design have been given in previous publications ,32,33,34Demographic , anthropometric, biochemical and dietary data were collected both at baseline (2001–2003) and after 10 years (2012–2013) using a structured, pretested, and validated interviewer-administered questionnaire . Family 2). Biochemical analyses, including fasting plasma glucose (FPG) and lipids, were performed in all individuals; in addition, plasma glucose estimation 2 h after a 75 g oral glucose load was performed in individuals without diabetes  and MS as shown in Consumption of 4 cups per day or more of unfermented dairy was associated with a lower incidence of high BMI and FPG  comparedp < 0.05) as shown in Consumption of 2 cups per day or more of fermented dairy was associated with a lower incidence of high FPG  comparedThe present study has found evidence of a protective effect of dairy consumption against CMR factors in Asian Indians. We found a reduced risk with an increased intake of dairy products, where consumption of ≥5 cups per day of total, ≥4 cups per day of unfermented or ≥2 cups per day of fermented dairy was associated with a reduced risk of high FPG. A total dairy intake of ≥5 cups per was also associated with a lower risk of high BP, low HDL and MS. Consumption of ≥4 cups per day of unfermented dairy was also associated with a decreased incidence of high BMI; while an intake of ≥2 cups per day of fermented dairy was also associated with a lower risk of MS. Given that Asian Indians have high prevalence of CVDs and T2D ,2,3,26, trendp < 0.0001]. Similarly, the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), which involved 9835 participants [p = 0.009). The French Data from the Epidemiological Study on the Insulin Resistance Syndrome (DESIR) [p = 0.01) and impaired fasting glycaemia/T2D . A prospective study of 7240 Koreans [trendp < 0.001) compared to no consumption of dairy. Overall, these findings indicate that consumption of dairy might be beneficial in reducing the risk of MS in different ethnic groups, but large dietary intervention studies will help to corroborate the findings.At baseline, the most widely consumed dairy products were reported to be tea and coffee with milk , and theicipants , observe (DESIR) , a cohor Koreans  also reptrendp = 0.02) and T2D . The Caerphilly Prospective Study of 2512 men [trendp = 0.023) than those who did not consume milk after a 22.8 year follow-up. This study [trendp = 0.032) with increasing intake of milk and dairy products. Furthermore, a cross-sectional study of 205 Indian participants with MS [p = 0.03). Moreover, a systematic review of randomised controlled trials [The inverse association between dairy consumption and the risk of individual components of CMR observed in our study is also consistent with previous studies. In the PURE study , a highe2512 men  also repis study  also obs with MS  showed t with MS  also foud trials  reportedp = 0.01) than a low intake, but this was not observed in our study. One possible explanation is that, cheese was a main part of fermented dairy in the Norwegian study [Our finding of a positive association between dairy intake and high HDL is also supported by a cohort study of 11,377 Norwegian participants (The Tromsø Study)  where coan study  while inThe average intake of SFA (% of energy) for this study population, Chennai urban area was 9% of total energy intake (TEI), which is within the recommended daily allowance of <10% of TEI . Dairy iThe strength of our study is the large sample size and the use of validated instruments in a well-characterised population. This study is one of few studies which have examined the association of total, unfermented and fermented dairy with the risk of MS in Asian Indians. Our study has some limitations. Comparing the benefits of fermented and unfermented dairy intake was not possible due to the relatively low intake of fermented dairy compared to unfermented dairy. Additionally, we did not investigate the effect of individual dairy products on the risk of MS. Furthermore, the fat content of the dairy products was not analysed in our study. Coffee and tea might also influence CVD risk independently as shown in We found that increased consumption of dairy  was associated with a lower risk of high FPG. A total dairy intake of ≥5 cups per day was also protective against high BP, low HDL and MS. A high unfermented dairy intake (≥4 cups per day) was also associated with a lower risk of high BMI, while a reduced risk of MS was observed with a fermented dairy intake of ≥2 cups per day. The findings indicate that increasing the consumption of dairy might help to reduce CMR factors  and MS in Asian Indians. Larger studies are needed to confirm our findings. Once our findings are confirmed, dietary guidelines focusing on increasing the consumption of dairy might be effective in reducing the risk of MS and components of CMR in Asian Indians.


Polyurethane elastomers (PUE), with superior mechanical properties and excellent corrosion resistance, are applied widely to the protective capability of structures under low-speed impact. However, they are prone to instantaneous phase transition, irreversible deformation and rupture even arising from holes under high-speed impact. In this paper, mussel adhesion proteins were applied to modify carbon nanofibers (CNFs) in a non-covalent way, and creatively mixed with PUE. This can improve the dispersity and interfacial compatibility of nanofillers in the PUE matrix. In addition, the homogeneous dispersion of modified nanofillers can serve as “reinforcing steel bars”. The nanofillers and PUE matrix can form “mud and brick” structures, which show superb mechanical properties and impact resistance. Specifically, the reinforcement of 1.0 wt.% modified fillers in PUE is 103.51%, 95.12% and 119.85% higher than the neat PUE in compression modulus, storage modulus and energy absorption capability, respectively. The results have great implications in the design of composite parts for aerospace and army vehicles under extreme circumstances. Polyurethane elastomers (PUEs) are a polymer material with a flexibly alternating arrangement of soft segments (SS) and hard segments (HS) to satisfy various needs of engineering applications, especially in dynamic events ,2, such High-speed impact occurs when high-velocity and high-energy shot/debris impact the target, which means that flexible protective equipment provides superior strength and resilience to absorb impact energy and avoid penetration ,8. AccorNatural mussels can robustly adhere to ships or rocks in turbulent waves, and some studies have found that mussel adhesive proteins, which contain covalent bonding and non-covalent bonding to improve the interfacial binding between substrate and adhesive proteins, have strong adhesion ability and can adhere to almost every substrate ,31,32. APUEs with excellent characteristics have a potential in high-speed impact applications after specific treatment. The previous research methods are complicated in process and high in cost, which are not suitable for mass production. Our experimental process is simple and suitable for large-scale application; the practical effect is remarkable and the cost is low. Inspired by mussel adhesive proteins in mussels, we used commercial dopamine hydrochloride to bionic design mussel adhesion proteins so as to improve the interfacial bonding between CNFs and PUEs, as shown in The PUEs, which consisted of an A component  and B component , –OH, 6.358 wt.%), were provided by Qingdao Green World New Material Technology Co., Ltd. Carbon nanofibers  were purchased from Xianfeng Nanotechnology Co. Other chemicals, including dopamine hydrochloride , hydrochloric acid  and Tris-HCl  were purchased from Aladdin.2O were added into the container, 0.05 mol/L HCl was used to adjust the PH to 8.5. 0.2 g DA, and 0.7 g CNFs were added into a flask and stirred at 25 °C for 24 h. They were washed several times with water to neutral, then filtered and dried at 60 °C for 24 h. These modified CNFs were named PDA@CNFs–1. Keeping the other reaction conditions constant, the concentration of DA was changed to 0.4 g and 0.8 g, named as PDA@CNFs–2 and PDA@CNFs–3, respectively. A total of 0.1 g Tris-HCl and 200 mL HThe PUEs and PDA@CNFs were added to the beaker and stirred for 10 min, and were put into a vacuum deaeration machine to pump air bubbles of PUE composites for 5 min. Finally, they were poured into the mold of the specified size and cured for 5 days. Thereinto, the mass ratio of A component to B component was maintained at 5:2. We controlled the mass fraction of these three fillers at 1.0 wt.%, and then successively added PUEs to prepare samples, named as PDA@CNFs/PUE–1, PDA@CNFs/PUE–2 and PDA@CNFs/PUE–-3. It was considered that PDA@CNFs–1 had the best dispersion in ethanol as shown in −1. The polymerization of CNFs was detected by a thermal gravimetric analyzer  in N2 at a heating rate of 20 °C/min. The surface chemical components of the nanoparticles were characterized by X-ray photoelectron spectroscopy . Absorption of the aqueous solution of nanofillers was measured with UV-VIS  from 550 nm to 260 nm. Scanning electron microscopy  was used to observe the distribution of nanofillers and fracture surface morphology of PUE composites after the SHPB test. An optical microscope  was used to observe the dispersity of CNFs and PDA@CNFs and surface damage conditions of PUE composites after dynamic impact. The universal electronic testing machine  was used for static compression test of PUE composites . Compression test parameters (such as compression modulus and compression resilience rate) were referenced from ISO 7743 2008(E) and GB/T 20671.2-2006, as shown in Formulas (1) and (2). The compression modulus was used to characterize the ability of the sample to resist deformation. The compression resilience rate was used to characterize the resilience of the material after compression.F: Compressive force (N)2)A: Initial cross-sectional area of sample  was obtained using a Nicolet 6700 with a scanning range of 3950–525 cmP: Sample thickness under initial loadM: Sample thickness at full loadR: Thickness of sample rebound−1. Three parallel experiments were conducted for all samples to take the average value. Dynamic mechanical analysis  was used to study the dynamic mechanical properties and interface problems of the solid viscoelastic properties. DMA test conditions were as follows: sample size: cuboid, 35 × 5 × 2 mm; tensile strain: 1.0%; dynamic strain: 0.2%; heating rate: 5 °C/min; frequency: 5 Hz; test temperature range: –60°C–70 °C. The dynamic impact resistance of composite PUEs  were measured by a split Hopkinson pressure bar  made of aluminum alloy.The strain rate of tests was set at 0.005 s−1), C-N (1231 cm−1) and C-O (1110 cm−1) are seen. As shown in An optical microscope was used to observe the dispersity of nanoparticles in an ethanol solution after 10 min ultrasonic and setting for 10 days, as shown in 3). Compared with the smooth surface of CNFs . Considering that PUEs exhibit obvious viscoelasticity and viscoplasticity during the compression process, it is necessary to study the compression modules and the compression resilience rate to indicate their strength and toughness ,43. It c1,b1, the strain–stress curves have excellent repeatability. Leaving the mass fraction of nanofiller as 1.0 wt.%, we find that PDA@CNFs/PUE–1 have better mechanical properties: higher compression modulus, compression resilience rate and maximum compressive strength. Besides, it is worthwhile to study the effect of different mass fractions of nanofillers on PUE. Therefore, we continued to design the five different mass fractions of PDA@CNFs–1 due to their good dispersity. The data show that, with the mass fraction increase of PDA@CNFs–1, the compression modulus, compression resilience rate and maximum compressive strength of composite PUEs first rise then fall, as shown in From The addition of PDA@CNFs can significantly influence the strength and toughness of PUE composites during the static compression test, which are beneficial for the following dynamic experiments.3, diameter Φ = 20 mm). Because the PUEs exhibited strain-rate dependency of its mechanical properties, it was necessary to control the same strain rate by controlling the gas pressure parameters of the apparatus at 20 °C to measure the dynamic impact effect on different mass fraction nanofillers on PUEs [−1 during the SHPB test  is favorable to avoid the inertia effect and end effect, and to maintain uniform deformation and stress balance more quickly, especially for soft materials such as PUEs ,5,43. Th on PUEs ,43,44. A on PUEs ,46, as stest see c. The extest see d,e. The The mechanical enhancement of polymer nanocomposites (PNCs) system mainly depends on the dispersion and interfacial compatibility of nanofillers in the matrix. Under extreme dynamic loading conditions, PUEs undergo a transient phase transition. When the pulse velocity approaches the corresponding segmental mobility, PUEs change from rubber to leather or even glass, which greatly increases the stress level and realizes greater energy dissipation .g is usually taken as the temperature corresponding to the peak of tan δ, reflecting the fluidity of polymer segments during experimental process [DMA tests have been widely applied to characterize the interface properties and solid viscoplasticity of heterogeneous PNCs. The variations in dissipation factor (Tan δ) and storage modulus (E’) with temperature are shown in  process .g of neat PUE is about –35.6 °C. It is obvious from the results that with an increase of content of PDA@CNFs, the E’ values soared dramatically while Tg first fell and then rose accordingly during the whole temperature range, as shown in g, which shows that CNFs can endow PUEs in strength but not toughness. However, PDA@CNFs have a potential to reduce the Tg of PUE composites with a small amount of mass fraction. In the cryogenic glass zone above the glass transition zone, the value of E’ increases significantly, because of elasticity and chain migration confinement effect of PDA@CNFs in the PUE matrix, while the Tan δ peak heights reduce and shift toward higher temperatures, which shows that adding more modified fillers will cause partial agglomeration of polymer composites to restrict the movement of chain joints and cause a decrease in the toughness of the material. Experiments verified that the modification and dispersion of CNFs in the PUE matrix can cause hydrodynamic enhancement effects, and the dispersion of nanofillers in the PUE is controlled by the modified state and mass fraction of nanofillers.The TOur works focus on the dynamic thermomechanical response and high-speed impact performance of PUE composites modified by PDA, and the effects of PDA@CNFs on PUE are discussed from the perspectives of chemical composition and structures. PDA can serve as “interfacial agents”, which provide π-π conjugation and hydrogen bonds, noncovalent bonding, and robust covalent bonding, such as amidogens and hydroxyls, crosslinking PUE to improve the interface interaction between CNFs and PUEs. We studied the effect of three different concentrations of DA to modify CNFs in PUE composites, and continued to investigate the effect of PDA@CNFs–1 mass fraction of PUE composites. To systemically study the mechanical properties of PDA@CNFs/PUE, we carried out static compression tests, SHPB tests and DMA experiments, then we observed the sections of PUE composites after SHPB tests. The experimental data show that adding tiny PDA@CNFs can significantly endow PUEs with a comprehensive mechanical performance and high-speed impact resistance via improving homogeneous dispersion, promoting interfacial bonding. The main experimental conclusions are as follows.(1)PDA can improve the dispersity of CNFs and compatibility between CNFs and PUE matrices.(2)PDA@CNFs/PUEs have excellent and comprehensive mechanical properties in static compression tests. The compression modulus and maximum strength of PC/PUE-Ⅳ were increased by 103.54% and 141.25%, respectively, compared with the neat PUE. The compression resilience rate of PC/PUE–Ⅳ was up to 82.6%, which was much better than the neat PUE and CNFs/PUE.(3)During the dynamic impact tests and DMA tests, PC/PUEs had excellent energy absorption capability, storage modulus and impact penetration resistance due to good dispersity and interface combination and “mud and brick” structures in the PUE composites.


A total of 19 bioactive compounds were detected in extracts prepared using SFE and SCE methods, whereas less than 12 compounds were detected in extracts obtained using the SXE method. Both the date variety and extraction method affected the phenolic profile of date flesh extract (p ≤ 0.05). The apparent viscosity, surface color, and bioactive properties of yogurt were affected by both date flesh extracts and storage duration in varied magnitudes (p ≤ 0.05). The incorporation of date flesh extracts into yogurt formulations increased the total phenolic content (TPC), DPPH antiradical activity, viscosity, and redness (a*) and decreased the lightness (L*) and yellowness (b*) of the developed product (p ≤ 0.05). The elongation of storage time progressively (p ≤ 0.05) reduced the pH, TPC, DPPH antiradical activity, bacterial counts, and L* and b* values and increased the acidity, syneresis, viscosity, and a* values with few exceptions. Date flesh extracts can improve the health quality of yogurt without major influence on the sensory attributes while stored at 4 °C.The bioactive compounds of four Saudi date flesh extracts (Ambara (AF), Majdool (MF), Sagai (SF), and Sukkari (SKF)) prepared using different extraction methods—namely, supercritical fluid extraction (SFE), subcritical CO Phytochemicals are linked with certain health benefits such as against the development of chronic diseases. Hence, their role carries significant importance. These are non-nutritive biological compounds from fruits, vegetables and grains, and more than 5000 phytochemicals have been identified from various plant materials with the possibility of a huge number still being unexplored . In ordeg others ,5. The mthers [2 ,7. Moreothers [2 .Phoenix dactylifera L.) is an important fruiting plant in various countries around the globe. The date fruit is generally considered healthy and a good source of energy [The date palm , the food industry is undergoing transitions and using new trends in product development. The development of functional food is aimed at not only fulfilling hunger but also providing additional health benefits. This trend is also correlated with increased life expectancy and the desire of the elderly for an improved life quality . There iLocally produced Sukari, Ambara, Majdool and Sagai date fruits were obtained from the Seasonal Date Fruit Market, Riyadh, Saudi Arabia. After separating from seeds manually, the date flesh was subjected to vacuum drying at 50 °C. The samples were then ground using a grinder . Ingredients for yogurt preparation were obtained from the local market. For analytical work, different chemicals and standards were obtained from Sigma-Aldrich .2 or SFE and subcritical CO2 or SCE) methods as described previously [2 flow rate. These SFE conditions were previously optimized [2 (6 kg) and 95% ethanol were used as solvent and cosolvent in SCE process, respectively [The extracts from the flesh of four different date fruits were prepared using conventional (Soxhlet) and modern . The system was connected to a mass spectrometer . The phytochemicals from dates were separated using a reverse-phase C18 column  . Acetic acid (2%) in water (A) and 100% acetonitrile (B) were used as a mobile phase in this study. The gradient conditions were set as reported previously . A 1 µL v/v) consisting of Streptococcus thermophilus and Lactobacillus delbrueckii subsp. bulgaricus  was added in a 1:1 ratio. The samples were then incubated at 44 °C for 4 h until they were fully coagulated (pH 4.6). The curd so formed was first cooled down to 4 °C in a refrigerator and then homogenized to form the liquefied drinkable yogurt. The final yogurt samples were then stored at 4 °C for carrying out various quality studies.Drinking yogurt was prepared in 7 different batches including control. The treatments included 6 yogurt samples each containing 1 g of dried extract from Majdool (MF) and Sukari (SKF) date flesh obtained using 3 different extraction techniques . These two varieties were selected due to their high phenolic contents and better antioxidant properties . A contrL* representing lightness or darkness, a* showing redness or greenness and b* demonstrating the yellowness and blueness of the samples. All physical parameters were evaluated in triplicates.The total solids or °Brix, pH, syneresis and acidity were measured . The anaThe sensory evaluation was carried out to determine the consistency, taste, odor and appearance of the yogurt on a 9-point scale where 1 was disliked extremely and 9 was liked extremely. The sensory panel included 20 semi-trained evaluators, and their informed consent was obtained about the use of natural date extracts in the samples. Samples were coded before presenting them to the evaluators, and water was used during the evaluation of different treatments.S. thermophilus) and MRS agar (pH 5.6) for the estimation of the population of S. thermophilus and L. bulgaricus, respectively. The yeast/mold count was carried out using potato dextrose agar. The inoculated plates were incubated at 45 °C under aerobic and anaerobic conditions for S. thermophilus and L. bulgaricus, respectively. The colony counting for LAB was performed after 3-day incubation. The yeast/mold count was performed after 5-day incubation plated at 37 °C. The results of microbial enumeration were presented as log CFU/g yogurt. The counting of yeast, and molds in all yogurt types was also carried out (no yeast and mold detected in freshly prepared yogurt) to confirm the process hygiene.The microbial analysis of yogurt samples was carried out to estimate the population of lactic acid bacteria (LAB) at different storage intervals. A yogurt sample of 1 g was added to sterile peptone water (9 mL) containing 0.1 g of peptone in 100 mL water. The samples were then serially diluted using peptone water (1:10). Afterwards, 1 mL of each of the diluted samples was added to M17 agar (6.5 pH) for estimation of g. The supernatant was separated and analyzed for TPC using Folin–Ciocalteu reagent (FCR). Followed by the incubation of a mixture containing supernatant, FCR and sodium carbonate (20%) at room temperature for 2 h, the absorbance values were recorded 765 nm using a spectrophotometer . Gallic acid was used as standard and results were expressed as mg of gallic acid equivalents (GAE).The total phenolic compounds (TPC) of yogurt samples were evaluated using the previously described method  with sliThe antioxidant activity was measured as DPPH  radical scavenging activity (%) as described previously  with somp < 0.05.All the extraction, analytical and product development studies were carried out in triplicates, and data were represented by means ± standard deviation (SD). A Duncan multiple range test was also used to compare mean values, and data were considered significantly different when 2 (SCE), and Soxhlet (SXE) extraction methods are shown in p ≤ 0.05) amounts of vanillic, ferulic, and cinnamic acids were observed in MF, whereas that of syringic acid was found in SKF extracted with the SXE method. In the SXE method, extraction was conducted using n-hexane at 70 °C for 10–12 h, and under these extreme conditions, thermal stable phenolic compounds could be extracted in high amounts due to the thermal disruption of a cell wall matrix, thereby enhancing the release of more soluble phenolic compounds. In addition, the elongated exposure of cellular fluid to repeated solvent recycling increased the liquefying properties of soluble components and hence increased the release and extractability of phenolic compounds [p ≤ 0.05) levels of rutin, quercetin-3-glucoside, luteolin, quercetin, apigenin, kaempferol, gallic, protocatechuic, chlorogenic, caffeic, and p-coumaric acids. The higher quantities of these phenolic compounds in SKF suggest that the application of the SCE method might have had positive effects on the recovery of these compounds. Moreover, the highest (p ≤ 0.05) levels of catechin, epicatechin, and naringenin were observed in SF extracted with the SCE method. Overall, SCE is the suitable extraction method for most of the phenolic compounds from date flesh followed by SFE, whereas the SXE extracted less amounts of a wide range (19 compounds) of phenolic compounds from all date types. The extraction of polar and nonpolar phenolic compounds by the combination of temperature and pressure used in the SCE and SFE methods could be the reason for the increased extraction of more phenolic compounds than SXE [The results of phenolic acids and flavonoid compounds in date flesh extracts of four date varieties (Ambara flesh (AF), Majdool flesh (MF), Sagai flesh (SF) and Sukari flesh (SKF)) as influenced by supercritical fluid (SFE), subcritical COompounds ,21. The than SXE ,22. Prevthan SXE . In thisthan SXE ,24,25.p ≤ 0.05) reduction in TSS at the end of storage that could be due to the metabolic process of fermenting microorganisms by which some nutrients could be degraded and hence resulted in the reduction in TSS [The results of physicochemical properties of functional yogurt containing date extracts of Majdool (MF) and Sukkari (SKF) fleshes prepared using different extraction  methods and stored at 4 °C for 20 days are shown in n in TSS .p ≤ 0.05) (p ≤ 0.05) reduced the pH and increased the acidity of control and date flesh extracts-containing yogurts except for the acidity of SFEMF and SFESKF yogurts, which was not affected by storage duration. The insignificant changes in the acidity of SFEMF and SFESKF yogurt samples during storage could be due to the presence of some bioactive compounds in these extracts that control the metabolic activity of lactic acid bacteria and maintain the steady bacterial growth during storage as reported previously in yogurt fortified with date spikelets extract [The pH and acidity of yogurt were not affected by the incorporation of date flesh extracts in the yogurt formulations, whereas they were influenced by storage duration ( ≤ 0.05) . A simil extract  and juju extract . The red extract ,30. In a extract ,31,32. T extract .p ≤ 0.05) influences of date flesh extracts on the syneresis (p ≤ 0.05) the syneresis of all yogurt samples to the maximum values at day 20 of storage with the highest overall syneresis value being observed in control yogurt, whereas SFEMF, SFESKE, and SCESKF yogurts showed low syneresis at the end of the storage period, suggesting that these date flesh extracts reduced the syneresis changes during the cold storage of functional yogurts and hence maintain the physical quality attributes of the fortified yogurts. The increase in acidity during the storage of yogurt could reduce the net negative charges of casein micelles and its colloid stability and thereby increase the separation of whey protein and water from yogurt clots. This ultimately results in an increment in yogurt syneresis [Syneresis is one of the important physical attributes of yogurt that can affect the storage stability and consumer acceptability of the product, and fewer changes in syneresis is preferable during the storage of yogurt . The synyneresis . Increasyneresis . A similyneresis , and oliyneresis  extractsyneresis ,32,36.p ≤ 0.05) influenced by both date flesh extracts and storage duration (p ≤ 0.05). The highest viscosity was observed in the control yogurt followed by SEFSKF and SXESKF yogurts at the end of storage, suggesting that the extraction method also affected the viscosity of the developed yogurts. Factors such as the post-acidification and formation of exopolysaccharide (EPS) by LAB cells under storage conditions, the interaction of formed EPS will milk components, and the interaction of phenolic compounds of date flesh extracts with yogurt protein could modify the yogurt gel network structure and thus increase the viscosity of the fortified yogurt during storage [The apparent viscosity of yogurt was significantly  increased the TPC and DPPH antiradical activity of the functional products. The highest TPC values were observed in SFEMF yogurt followed by SCEMF yogurt samples, whereas the lowest values were found in control yogurt throughout the entire storage period (p ≤ 0.05). The highest DPPH antiradical activity value was seen in fresh SCEMF yogurt samples followed by that of fresh SFEMF and SCESKF yogurts (p ≤ 0.05). Among yogurts containing different date flesh extracts, SXESKF yogurts showed the lowest TPC followed by SFESKF and SXEMF, suggesting that the extraction method and date type also influenced the TPC of functional yogurts. The increase in the TPC and DPPH antiradical activity of yogurt fortified with date flesh extracts is due to high level of phenolic compounds in date flesh extracts prepared using different extraction methods [Pleurotus ostreatus aqueous extract [p ≤ 0.05). The reduction in TPC and the DPPH antiradical activity of yogurt samples during storage could be due to the influence of oxygen and metabolic enzymes from lactic acid bacteria and the degradation of certain polyphenols. Additionally, the reduced extractability of phenolic compounds from a yogurt matrix may also be due to the formation of complexes between phenolic compounds of date flesh extracts and yogurt proteins (protein–polyphenols interactions) [The total phenolic content (TPC) and DPPH antiradical activity of yogurt were influenced positively by date flesh extract addition and negatively by storage time elongation . The inc methods . These f extract , moringa extract , chia se extract , olive l extract  and date extract . During actions) ,42,43,44actions) ,42,43,44Lactobacillus bulgaricus and Streptococcus thermophiles) counts in fresh and stored yogurt samples were high (7.35–9.71 log CFU/mL) and were not affected by the addition of date flesh extracts (L. bulgaricus and S. thermophiles were progressively (p ≤ 0.05) reduced as the storage period elongated of control and SXESKF yogurts, whereas that of all other yogurts fortified with date flesh extracts remained constant during the first 10 days of storage and then reduced at the end of storage except for the count of L. bulgaricus in SFESKF, which increased at the end of storage. The decline of LAB counts during storage is likely due to the pH reduction and acidity increase in yogurt during storage [Starter culture lactic acid bacteria ; redness to greenness (a*) and yellowness to blueness (b*)) of functional yogurt fortified with extracts of Majdool and Sukkari date flesh prepared using different extraction methods  and stored at 4 °C for up to 20 days are presented in L* values of yogurt were greatly reduced by the incorporation of date flesh extract and storage duration (p ≤ 0.05). The maximum L* values were seen in fresh and stored control yogurt, and the minimum L* value was observed in SXESKF yogurt at day 20 of storage. The redness (a*) values were increased (p ≤ 0.05) following the addition of date flesh extracts to yogurt formulations, and low (p ≤ 0.05) values were seen in control yogurts compared to fortified ones. In addition, the a* values of all yogurt samples were concurrently (p ≤ 0.05) increased as the storage period progressed, reaching maximum values at the end of the storage period. Among all yogurt samples, the highest a* value was observed in SCESKF yogurt followed by that of SCEMF at day 20 of storage, whereas the lowest values were seen in control yogurt on day 1 of storage (p ≤ 0.05). The yellowness (b*) values of yogurt samples were affected by the date flesh extracts and storage duration in a different manner. The highest b* values of all yogurt samples were seen in fresh yogurt samples, and as the storage time progressed, the b* values reduced to the lowest values at day 20 of storage (p ≤ 0.05). The reduction in L* values and increase in a* values in fortified yogurts is likely due to the brown color of the added date flesh extracts. Similarly, a reduction in L* values and an increase in a* values of yogurts fortified with natural antioxidant extracts have been reported in various studies [L* and b* values of yogurt samples during storage is probably due to the structural changes of the gel network structure, which reduced the free water on the surface of fortified yogurt and thereby reduced the lightness and yellowness values of the functional yogurts [a* of fortified yogurt during storage could be attributed to the acidity development and structural modifications of yogurt’s three-dimensional structure that promote the release of red pigments of date flesh extracts from the yogurt matrix into the surface and thereby increased redness values during the storage of fortified yogurts [Surface color is one of the physical quality attributes that influences the marketing and consumer preferences for yogurt . Determi studies ,37,42. T yogurts . Whereas yogurts . In agre yogurts ,42,47.The sensory attributes  of functional yogurt fortified with extracts of Majdool and Sukkari date flesh prepared using different extraction methods  and stored at 4 °C for up to 20 days are presented in 2 extraction (SCE)) as well as conventional Soxhlet extraction (SXE) methods. The quantity and composition of phenolic compounds in date flesh extracts are influenced by both date variety and extraction methods. The incorporation of date flesh extracts into yogurt formulations significantly improved the bioactive properties , physical properties (viscosity and syneresis), and probiotic potential (LAB counts of more than 7.8 CFU/mL) and overcome adverse effects of prolonged storage on the overall quality attributes of the developed functional yogurt. In addition, the sensory acceptability of the developed functional yogurt was greatly conserved during storage as fewer changes in sensory attributes were observed in functional yogurts during storage. Overall, date flesh extracts can improve the nutritional and health quality of yogurt without a major influence on the sensory attributes of the product during refrigerated storage.This study concludes that date flesh is rich in phenolic compounds that were effectively recovered by using innovative green extraction  and subcritical CO


RTBFR; n = 7) or TRT . Both resistance training protocols had 36 sessions . Protocol intensity was 30% (GRTBFR) and 80% (GTRT). Hemodynamic  and lipid profile were acutely  and chronically (pre and post-program) recorded. General linear models were applied to determine group * time interaction. In the comparisons between groups, the resistance training program showed acute adaptations: hemodynamic responses were not different (p > 0.05), regardless of the assessment session; and chronicles: changes in lipidic profile favors GRTBFR, which significantly lower level of total cholesterol (p = 0.024), triglycerides (p = 0.002) and LDL (p = 0.030) compared to GTRT. RTBFR and TRT induced a similar hemodynamic adaptation in PWH, with no significant risks of increased cardiovascular stress. Additionally, RTBFR promoted better chronic adequacy of lipid profile than TRT. Therefore, RTBFR presents a safe resistance training alternative for PWH.Resistance training with blood flow restriction (RTBFR) allows physically impaired people living with HIV (PWH) to exercise at lower intensities than traditional resistance training (TRT). But the acute and chronic cardiac and metabolic responses of PWH following an RTBFR protocol are unknown. The objective was to compare the safety of acute and chronic effects on hemodynamic and lipid profiles between TRT or RTBFR in PWH. In this randomized control trial, 14 PWH were allocated in RTBFR (GTrial registration: ClinicalTrials.gov ID: NCT02783417; Date of registration: 26/05/2016. However, cardiometabolic disorders such as dyslipidemia, insulin resistance, diabetes, hypertension, and increased inflammatory state are frequently observed amongst people living with HIV (PWH)3. The etiology of the abovementioned cardiometabolic abnormalities is complex and multifactorial and might be related to the inflammatory effects caused by the virus infection itself and/or by the ART treatment4. As a consequence, PWH exhibits an augmented cardiovascular risk6.Antiretroviral therapy (ART) increased life expectancy in people diagnosed with Human Immunodeficiency Virus (HIV)7. Indeed, regular physical exercise, including traditional resistance training (TRT) in PWH, is recommended as an adjuvant therapy once it improves cardiovascular health8, lipid profile9, cardiorespiratory fitness, muscle strength, and body composition10. Additional benefits such as muscle hypertrophy are conferred by TRT at high intensities 11. However, intensities of this magnitude may be contraindicated for debilitated PWH, who often have physical incapacities and/or high cardiovascular risk13.To counteract the adverse metabolic side effects of ART and infection, PWH is therefore encouraged to adopt a healthy lifestyle, with complementary physical exercise therapies15 because the ability to express strength is suppressed by restrictive cuffs on practitioners’ limbs. These cuffs evoke a considerable vascular stress16 which arises from both exogenous mechanical compression of the vessel and endogenous muscular compression. The resultant compression limits the capacity to exercise at high intensities and triggers several physiological mechanisms depicted in Fig. 19.Resistance training with blood flow restriction (RTBFR) might configure an alternative approach to high-intensity TRT. This method is performed at low intensities (20% to 40% 1RM)20 and in PWH4 samples. Our previous founds demonstrate that are no significant differences in the effects of the two training methods (RTBFR and TRT) on muscle function and its morphology4. Although the methods strategically differ in terms of load, frequency, and ischemia, there is no difference in terms of training volume and muscle increase4. So, this study only looks at cardiovascular data in the same subject group (previously published) to examine the safety of these two types of training. Although RTBFR has been applied in diverse populations22; its safety regarding the acute hemodynamic responses is not yet fully established, and available results are conflicting. For example, some authors have demonstrated a superior increase in heart rate and blood pressure during RTBFR compared to TRT23. Others showed an equal or even a slighter response in the aforementioned variables following an RTBFR in comparison with TRT24. In terms of chronic effects of RTBFR on cardiovascular risk factors, studies results are attractive regarding blood pressure25 and metabolic profile27 for HIV-seronegative individuals. However, those researches looking for the effects of RTBFR on chronic cardiometabolic and hemodynamic factors in PWH are limited despite the high prevalence of systemic hypertension amongst this population28.The RTBFR increases muscle strength and muscle mass similar to the high-intensity TRT both in healthy12.Thus, our study purposes were (i) to compare the safety of acute response of RTBFR and TRT on hemodynamic variables  in PWH; and (ii) to verify the chronic hemodynamic and metabolic adaptations of RTBFR and TRT in PWH after 12 weeks of training. We hypothesize that both RTBFR and TRT lead to a similar acute response of hemodynamic variables. At least in healthy subjects, both types of training (RTBFR and TRT) there is a similar acute blood lactate elevation, and equal or lower hemodynamic responses in RTBFR compared to TRT3 and viral load > 100,000 copies of RNA/mL); cardiovascular disease symptoms of or opportunistic infections; and if they missed more than nine non-consecutive training sessions (> 25%).A non-probabilistic sample  of adults with PWH participated in the study. Inclusion criteria were: seropositive for HIV; aged between 30 and 60 years; not be pregnant; do not participate in any regular physical exercise program for at least three months; regular treatment with ART; body weight variation < 10% in the last six months; ankle/brachial index between 0.91 and 1.30; and have a physician clearance to integrate the exercise program. Participants were excluded if they presented symptoms that contraindicated their permanence in the training program  or a group of traditional resistance training  14; and the GTRT, at 80%, as recommended by the American College of Sports Medicine to optimize hypertrophy . Eligible participants were personally recruited during their clinic’s routine appointments in the Clinical Hospital Medical School at Ribeirao Preto/University of São Paulo; and in the Municipal Health Departments of the cities of Ribeirao Preto and Batatais, Southeast Brazil. There was a place for a single appointment in which participants provide sociodemographic information and they were assessed for cardiometabolic  and physiological parameters. After, participants were assessed for anthropometric and 1RM. To minimize errors, all measurements were performed by a single trained technician to limit measurement errors. The participants were equally and randomly distributed in quartiles according to the initial 1RM test (muscle strength levels) in a group of resistance training with blood flow restriction , use of medication for hypertension, comorbidities, and risk factors for thrombosis were gathered via interviews and patients’ clinical files. Patients’ clinical files access was authorized by the Hospital Ethics Committee.30. Measures were gathered with an aneroid sphygmomanometer  and a vascular doppler probe . The ankle-brachial index (ABI) was obtained (for both sides) by the ratio of the systolic blood pressure (SBP) measured at the ankle to that measured at the brachial artery. For security considerations, ankle/brachial index lower than 0.91 or higher than 1.30 indicated the presence of peripheral obstructive arterial disease30. Then, the training was not done.Systolic blood pressures (SBP) were obtained in 8 anatomical regions  while participants were at supine position®, PAIS). Detailed procedures are described elsewhere4. In brief, participants were lying down in the supine position, and cuffs were fixed on the participant’s limbs and inflated until the point where auscultatory monitored pulses were interrupted. Upper and lower body pressures at these points were used as 100% BFR and applied during training sessions for the GRTBFR. Higher BRF pressure (> 80%) has a greater muscle activation compared to milder intensities (40 or 60%)31.The pressure to complete blood flow restriction  was assessed using a Doppler vascular probe  and specific lower (170 × 900 mm) and upper body cuffs (70 × 730 mm)  is reduced or augmented to allow one to 10 repetitions. Participants had up to three attempts, with a 3-min rest interval between them. The test was carried out during the pre-intervention period and in the training sessions number 6, 21, and 36  protocol. According to this, participants should perform proper repetitions in terms of velocity and range of motion until the failure, without exceeding 10 repetitions33 and Brazilian Society of Hypertension procedures34. All hemodynamic measures were always executed by the same investigator (TCA).Before each training session, heart rate and blood pressure were measured according to®; Embu das Artes/Brazil). It was also measured immediately post exercises.Resting heart rate (RHR) was measured after five-minute resting in the sitting position using the heart rate monitor . Participants remained seated with the left arm supported at the heart level. Blood pressure was measured twice one minute apart. Additional measurements were taken if differences were higher than 5 mmHg for both SBP and DBP. The mean values between the two closer attempts were assumed as final SBP and DPB, as recommended11. The presence of hypertension was assumed if SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg were observed on two different days and/or if participants were undertaking antihypertension drugs11. BP was also measured between 20 and 30 s after the last repetition of the triceps exercise (intermediate BP), and between 20 and 30 s after the last repetition of the last set of the quadriceps exercise (post-exercise BP).Resting SBP and diastolic blood pressure (DBP) were measured immediately after the RHR procedure (rest BP), using a stethoscope and aneroid sphygmomanometer (Premium35 and DP (HR * SBP)36 were computed. Hemodynamic parameters were assessed pre and post-intervention at rest, and post each exercise in sessions numbers 7, 22, and 35 ]/3) * DBP]/3®; Sao Paulo/Brazil), was used to get results. The lipidic profile was classified according to the NCEP ATP III and the dyslipidemia was confirmed when TC > 200 mg/dL and/or HDL < 40 mg/dL and/or TG > 150 mg/dL and/or LDL > 130 mg/dL37.Lipidic profile  and glycaemia (blood glucose) were determined pre-and post-training Fig. . Blood s11.Intensities for each group were established based on 1RM estimation. Each exercise session for both groups had four exercises executed one at a time in the following sequence: arm curl (biceps); arm extension (triceps); unilateral leg curl (hamstring); and leg extension (quadriceps). Resistance exercises were performed in an Athletic Way Training Station, with two independent 180 kg load columns. The training session was only initiated after getting vital signs within acceptable values The 36 training sessions were divided into adaptation and specific phases. The adaptation phase lasted six sessions and was equal regardless of the group. In this phase, sessions had a 5-min warm-up period on a stationary cycle ergometer (load up to 60 rpm) plus resistance exercises (1 set × 12 repetitions × 50% 1RM). The 30-specific training sessions were specific according to the groups but the warm-up was similar . Details about the training protocols are depicted in Fig. 4.The volume of each exercise and each session (sum of the four exercises) were performed at the end of the adaptation phase (6th session), 7th week (21st session) and at the end of the 12th week (36th session). Thus, the total training load (nº of series × nº of reps × weight [kg]) was compared in three moments, at the 6th, 21st, and 36th sessions38. The chemical analysis of energy intake  was performed with the nutritional coefficients of the Brazilian Food Composition Table (TACO)39 and with the National Nutrient Database for Standard Reference (USDA)40. The average of the 3 days of energy and macronutrient intake  was considered.Because diet might impact training responses, participants were assessed for nutrition. The 24-h food record was used to determine the energy intake from food consumption, and it was applied on two weekdays and one weekend day, at the beginning and at the end of the study (3rd and 11th week). Participants registered all consumed products in detail. The first day of the 24-h food record was the day before the patient's assessmentversus TRT) were verified using an independent t-test, chi-square, and Mann–Whitney U test, as appropriate. Training volume comparisons according to exercise groups were checked using the independent t-test to ensure that any differences in responses between training types were not due to differences in training volume. Group changes over time  were ascertained using paired t-test or Wilcoxon test. Acute and chronic changes were adjusted for antihypertensive treatment in hemodynamic variables during each intragroup session and comparisons between groups were performed by GLM (group-by-time interactions). The SIDAK post hoc test was selected to verify between groups and moments differences when significant F values were found in the main effect comparisons. The delta of the alteration of the variables was calculated through the difference between the values after and pre-exercise and intervention, to verify the magnitude of the alteration provided by each training method on all the studied variables. To verify the impact of training methods on all studied variables the effect size (ES) was calculated ([Post-test mean – pre-test mean]/pretest standard deviation)41 and classified  according to Rhea (2004). All analyses were performed assuming statistical significance previously (p < 0.05) on SPSS 20.0.Power calculation was computed a priori using the software G*Power version 3.1. Considering a repeated measures design, for the within-between interaction, the sample size revealed that 24 subjects (12 per group) were required to detect a medium effect size (f = 0.25). The other parameters considered were a power of 80%, an error type I of 0.05, three measurements , two groups (RTBFR and TRT), and assuming a correlation equal to 0.60, and a no sphericity correction of 1.0. Data normality was checked with Shapiro–Wilk test. Descriptive statistics  were used to describe the sample. At baseline, between groups comparisons (RTBFR The study was approved by the Research Ethics Committee of the University of Sao Paulo School of Nursing at Ribeirao Preto (EERP/USP). It followed the recommendations that govern research involving human beings, which are also in accordance with the Declaration of Helsinki. This study was registered in ClinicalTrials.gov ID: NCT02783417, under protocol ID: 44195315.6.0000.5393. Date of registration: May 26, 2016.Informed consent was obtained from all individual participants included in the study.RTBFR:11; GTRT: 14). At the end of the protocol, each exercise group had 7 participants .Table RTBFR were 135.7 ± 12.7 and 124.3 ± 15.1 mmHg, for the upper and lower body, respectively.The BFR for training in GRTBFR , HR  and DP  and in the 35th session, the GRTBFR showed a statistically significant increase for HR  and DP   Fig. .Figure 4TRT, significantly increments were observed for HR  and DP . In the 22nd session the GTRT for SBP , HR  and DP  and in the 35th session showed a statistically increments for SBP , HR  and DP   Fig. .RTBFR presented a large ES classification for all hemodynamic parameters  in the 7th training session , HR (ES = 2.34), and DP (ES = 2.43)] during the same session , HR (6.25), and DP (8.41) while the GRTBFR presented a moderate ES classification only for DP (1.5). In the 35th session, the GTRT sustained a large ES for SBP (4.04), HR (3.68), and DP (5.07) whereas the GRTBFR, had a moderate ES for HR (1.54) and DP (1.86)  Fig. .Between groups comparisons for acute hemodynamics did not show any significant difference at the different moments of assessment  Fig. .RTBFR on TC , TG , LDL , and HDL , and for GTRT on TC , TG , LDL , and   Fig. .Figure 5RTBFR compared to GTRT had a lower mean for TC , TG  and LDL-cholesterol   for lipidic and hemodynamic indexes according to exercise interventions are depicted in Fig. RTBFR: 1042.9 versus GTRT: 1050.0; p = 0.972) 21st  and 36th , indicating that training volume across groups were not different. Table Groups exhibit similar training loads at sessions number 6st , suggesting a faster and notably significant response to training to the PWH more weakened. Moreover, RTBFR provoked a superior lipidic profile adaptation in PWH compared to TRT. According to the best of our knowledge, the inexistence of other studies including similar training approaches by PWH4 difficult between studies comparisons.This randomized controlled trial aimed to compare the safety of acute (rest versus post-exercise conditions) and chronic (before and after 12 weeks of training) responses to hemodynamic  and lipid variables from two strength training approaches (RTBFR versus TRT) in the PWH. The results in muscle strength and volumes of these patients have already been demonstrated in our previous study42. Both exercise protocols prompted a similar increase in HR and DP. The RTBFR induces an additional exogenous mechanical compression of blood vessels and an endogenous muscle compression, that together exacerbate blood pressure and HR responses during an RTBFR training session compared to TRT16. The physiological mechanism underlying this phenomenon is that the venous vascular occlusion augments metabolite accumulation, which stimulates muscle chemoreceptors to produce and release catecholamines through the stimulus of the sympathetic nervous system43. In RTBFR, there is a reduction in blood flow to the exercised muscle. Reduced blood flow during muscle contraction increases metabolic stress and may increase muscle or reflex pressure to the cardiovascular control center, causing exaggerated sympathetic nerve activity. Increased sympathetic activity can lead to increased peripheral vascular resistance and, consequently, increase DBP during exercise44. Moreover, other factors  may contribute to an additional HR and BP intensification during RTBFR45. Surprisingly, in our findings, the RTBFR until the concentric failure (meaning a huge intensity/volume) did not evoke greater hemodynamic stress. It is possible to suggest that the cuff releasing during intervals between sets and exercises probably reduced the impact that exercise could exert on central nervous system responses, and consequently, on HR and SBP43.The acute hemodynamic response during a resistance training bout is controlled by the brain stem which important neural mechanism of central command, taking into account a combination of the mechanical changes in muscles and tendons  and the accumulation of metabolites in the active contracting muscle (i.e. muscle metaboreflex)12 or both, upper and lower limbs46. Our results with PWH are aligned with those findings. Despite the lack of statistical differences, in the GRTBFR group, the ES of hemodynamic variables exhibited a trend to decrease along with the study protocol. Conversely, an opposite trend was observed for the GTRT. We might suggest that this indicates an adaptation to the type of training triggered by attenuation of discomfort or pain felt by the GRTBFR participants arising from metabolic acidosis47, which generally impacts increased hemodynamic responses.Previous acute studies have shown that BP and HR responses induced by both RTBFR and TRT are similar for limbs involved in the training program, even when exercise protocols have involved just lowerRTBFR at the end of the protocol . These findings suggest that RTBFR might be useful to manage dyslipidemia induced by ART drugs. However, it is important to highlight that this result must be interpreted with caution due to the small sample size.In terms of chronic adaptations for hemodynamic responses, results between and within groups were similar. For the lipidic profile, there was observed a minimal positive variation favoring the G48. The lipoprotein lipase activity enzyme favors the exit of TG fatty acids from the adipose and muscle tissues, which increases TG catabolism and facilitates the removal of TG from the bloodstream26. As above mentioned, the GRTBFR showed an improvement in the lipidic profile, which might be partially explained by an expressive blood secretion of growth hormone following the RTBFR50. It is speculated that the growth hormone signals protein synthesis by modulating insulin-like growth factor I (IGF-1)22. In addition, the growth hormone also increases lipolysis enhancing the reduction of visceral fat and positively affecting circulating lipids22, typically up-regulated in PWH. Figure Resistance training improves cardiometabolic profile via lipoprotein lipase activity enzyme stimulation and thus, it may protect against the onset of health conditions such as atherosclerosis, metabolic syndrome, and cardiovascular diseasesor I IGF-22. In adTRT protocol. The available literature highlights the improvement both in lipidic and metabolic profiles in PWH undergoing TRT51. However, it is common degradation of the lipid profile in PWH and therefore, any maintenance of lipids would already represent a clinical advantage. Despite it, the baseline TG values presented by the GTRT (182 mg dL−1) were above the 150 mg dL−1 and it did not change at the end of the protocol. It is still unclear why there was a positive trend change in the TG level only in the GRTBFR. The increase in muscle mass may increase the elimination of TG in the circulation51. However, PWH with lipodystrophy are characterized by mitochondrial dysfunction and this may represent one of the underlying mechanisms for dyslipidemia in this population. Therefore, the TRT effect on mitochondrial biogenesis and lipid oxidation may not have been achieved in our study9.An unexpected result was the lipidic profile deterioration at the end of the GRTBFR had a slightly lower HR and DP at the end of exercise sessions, suggesting an eventual tendency of superior hemodynamic stability, potentially masked by the small sample size.Our study further monitored the chronic hemodynamic and metabolic effects of RTBFR and TRT considering similar training volumes. During the 12 weeks of intervention, the training intensities of both groups remained stable although the exercise loads were adjusted according to the 1-RM reassessments. Regardless of the lack of significant changes between groups, the G52. Chronic administration of antihypertensive drugs would likely result in suitable BP before the start of the study. We detected 3 cases in each intervention group (RTBFR and TRT), but we did not have access to the information on the antihypertensive treatment duration. To solve this impasse, we proceed with data analysis without controlling for antihypertensive drugs, and the results did not change (data not shown). This is particularly important because cardiometabolic abnormalities, including hypertension, are highly prevalent amongst PWH6. Between studies, the comparison is difficult because there was only one study on RTBFR with similar aims to ours, but in this case, the sample was older adults with coronary artery disease. In this study, eight weeks of RTBFR  induced a decrease in resting SBP, but, immediately after the training session, SBP increased of the same magnitude throughout the intervention period25.Although the frequency of antihypertensive drugs was the same in both groups, we decided to adjust our analysis to it, due they exert a physiological impact on acute and chronic hemodynamic adaptations. This is especially true considering that many antihypertensive classes could be administered for different periods to participants53, and requires a bigger muscle volume, impacting more exuberant acute hemodynamic adaptations43. Our results were pioneering in showing that whole body RTBFR did not induce a bigger hemodynamic response compared to TRT, demonstrating that the method seems safe from the circulatory system point of view in a particular clinically debilitated populations54. The fact that the training volume was controlled and that it was similar in both groups along the study protocol overcome the usual limitation (different training volumes across studies groups) pointed out in many studies looking at the acute and chronic effects of exercise interventions. Additionally, the random distribution of participants balanced according to 1RM ensured homogeneity between groups at baseline, strengthening the comparisons between training methods. Finally, the consideration of food intake along the protocol prevented an eventual intragroup dietary difference in the type of training/adaptation. In combination, all these methodological details ensure that there was no influence of baseline differences in terms of strength, training load (volume), and diet on the results.To the best of our knowledge, this is the first study measuring the impact of RTBFR on hemodynamic and metabolic profiles in PWH. As far as we know, most studies using RTBFR include exercises for the upper or lower body hampering comparability against TRT . The protocol adopted by us included two exercises for the lower and two for the upper body in the same session, which is more close to daily resistance training routines55. Another limitation was the intermittent monitoring of BP instead continuous . This might have compromised the recording of pressure peaks during exercise performance, which could be above the ones observed immediately after the exercise series12.Despite the small sample size, this is a very particular (and difficult) population to recruit and to carry on a randomized controlled trial as we did. Immunological disbalance, low income, and social exclusion are some of the barriers to PWH for the availability to participate and attend training sessions, alongside a higher prevalence of cognitive difficulties or depression53. However, the same institution assumes that evidence (and its level) that has supported these recommendations are very low11 reinforcing the need to verify the best resistance training approach exerting the superior health benefit. Depending on the HIV status (asymptomatic and symptomatic), care must be taken with the assessment of functional, hemodynamic, and metabolic parameters of PWH7. In asymptomatic patients, physiological parameters  are normal but there may be low aerobic impairment (if sedentary)7. When in the symptomatic phase, PWH has reduced aerobic capacity and muscle strength, the possibility of an increased resting heart rate and submaximal work rates, difficulties in adhering to exercise programs, and side effects related to antiretroviral therapy. In the stronger symptomatic phase status, there is a drastic reduction in aerobic capacity and muscle strength, in addition to a possible abnormal endocrine response at moderate and high-intensity work rates7. Both RTBFR and TRT induce muscle hypertrophy and promote desirable body composition changes in PWH4. The larger impact of RTBFR on lipid profile suggests the superiority of this method for PWH, whose population usually has dyslipidemia3, closely linked to an augmented cardiovascular risk. Although our study results failed in showing a chronic hypotensive effect of RTBFR, it was observed a trend toward lower hemodynamic stress in PWH compared to TRT. Considering the abovementioned, the RTBFR seems to be a safe strength training methodology for more fragile PWH.The American College of Sports Medicine encourages PWH to perform TRT The RTBFR showed no different performance than TRT, proving to be a safer alternative therapy by resistance training method for PWH. Frail patients could be favored by training with BFR instead TRT because it is performed at lower intensities, induced similar chronic and acute hemodynamic responses, and seems to be superior in terms of lipids regulation. Indeed, the impact of RTBFR on the serum-lipid profile suggests its cardioprotective effect. The clinical significance for the health of PWH is that integrative practices, such as resistance training, contribute to lesser susceptibility to chronic non-communicable diseases. Thus, we conclude that RTBFR can be considered a safe complementary therapy in the treatment of PWH.Supplementary Tables.


Independent predictors for troponin enhancement were acute coronary syndrome presentation, renal failure, elevated C-Reactive protein and multiple lesions treated with RA. Conclusion: Troponin release did not differ among treatment arms. Our results suggest that greater platelet inhibition does not affect periprocedural myocardial necrosis in the setting of RA.Background: Because rotational atherectomy (RA) is associated with arterial trauma and platelet activation, patients treated with RA may benefit from more potent antiplatelet drugs. The aim of this trial was to assess the superiority of ticagrelor over clopidogrel in reducing post procedure troponin release. Methods: TIRATROP  is a multicenter double-blind randomized controlled trial that included 180 patients with severe calcified lesions requiring RA who received either clopidogrel  or ticagrelor (loading dose 180 mg then 90 mg twice daily). Blood samples were collected at the beginning (T0), and 6, 12, 18, 24 and 36 h after the procedure. Primary end point was troponin release within the first 24 h using area under the curve analysis (troponin level as a function of time). Results: The mean age of patients was 76 ± 10 years, 35% had diabetes. RA was used to treat 1, 2 or 3 calcified lesions in 72%, 23% and 5% of patients, respectively. Troponin release within the first 24 h was similar in both the ticagrelor (adjusted mean ±SD of ln AUC 8.85 ± 0.33) and the clopidogrel (8.77 ± 0.34,  Inhibition of P2Y12 receptor combined with aspirin is still the cornerstone therapy for patients undergoing percutaneous coronary intervention (PCI). Three oral P2Y12 inhibitors with substantial pharmacokinetic and pharmacodynamic differences are currently on the market: clopidogrel and prasugrel–second and third generation thienopyridine, and ticagrelor, a non-thienopyridine P2Y12 inhibitor. Ticagrelor is a direct-acting drug that provides faster and greater P2Y12 inhibition than clopidogrel . TicagreThe impact of more potent P2Y12 inhibitors on ischemic complications of RA is unknown. In the TIRATROP study , we assessed whether ticagrelor would be superior to clopidogrel to lower periprocedural troponin release following RA.The TIRATROP study was a multicentric (4 centers across the French metropolitan territory) superiority randomized (1:1) double-blind controlled study that compared ticagrelor and clopidogrel through a parallel group design. Stable CAD patients (stable angina or silent ischemia) or patients presenting with a non ST-elevation ACS with normal troponin level or normal CK-MB level (<3 times the upper limit of the laboratory) at the time of the procedure with at least one de novo highly calcified lesion eligible for RA procedure in a native vessel were screened for inclusion. The main exclusion criteria were ACS with troponin elevation before PCI, patients treated with GpIIbIIIa inhibitors and presence of contraindication to ticagrelor. The complete list of exclusion criteria is presented in online-only All interventions were performed by experienced operators using conventional technique and a standard antithrombotic therapy beside the P2Y12 regimen: aspirin 75 to 160 mg daily started at least the day before the procedure–and continued indefinitely–and parenteral heparin bolus (60–70 UI/kg). Ticagrelor or clopidogrel was administered in a double-blind manner. In the intervention group, ticagrelor was administered orally according to the following scheme: 180 mg on the evening preceding—and at least 6 h before—the index procedure (Day − 1), 90 mg on the morning of the procedure  and 90 mg in the evening , and then, 90 mg, twice, on the day following the index procedure (Day + 1). In the control group, clopidogrel was administered orally according to the following scheme: 300 mg on the evening preceding—and at least 6 h before—the index procedure (Day − 1), 75 mg on the morning of the procedure  and 0 mg in the evening , and then, 75 mg once, on the day following the index procedure (Day + 1). The maintenance dose of P2Y12 inhibitors was administered until hospital discharge according to randomization. In order to ensure blindness, patients in the intervention group took active pills of ticagrelor and placebo pills of clopidogrel and vice versa for patients in the control group. Differences between active and placebo pills were not distinguishable to the naked eye. Randomization was stratified upon recruitment center and patient’s clinical status (stable or following an ACS). In each stratum, a design based on randomized blocks of 2 to 4 patients was applied according to a 1:1 ratio. After each patient’s inclusion, investigators logged onto a secured website to obtain the number of the corresponding treatment kit following the pre-established randomization list.®, Boston Scientific Corp., Natick, MA, USA). The smallest burr necessary to create a channel to modify the plaque and to facilitate the delivery of other devices was encouraged. A pressured rotablator-flush solution was infused into the device . Following ablation, balloon predilatation and stent implantation were highly recommended. Baseline clinical, angiographic and procedural characteristics were recorded in a case report form. Discharge treatments were left to the investigator’s choice. A systematic phone call to the patient was scheduled 30 days after the procedure to collect any medical event that may have occurred following hospital discharge. Three study populations were preliminarily defined: (1) the “Intention To Treat” (ITT) population: all patients included in the cohort, with at least 1 blood sample after the procedure, (2) the “Per-Protocole” population: all ITT patients with no major protocol deviation, and (3) the “Safety population”: all patients included who received at least one dose of treatment.The interventional strategy was at the discretion of the physician. RA was performed with a Rotablator coronary system  measurement. After the procedure, 5 sets of HS-TnT were measured . HS-cTnT was measured with the Roche hs-cTnT assay (Roche Diagnostics) . After cThe primary end point was HS-TnT release within 24 h following the index procedure assessed as an area under the curve (AUC) and corresponding to troponin level (ng/mL) as a function of time (hours). Measurements were computed using the trapezoidal rule with the “pkexamine” Stata’s command, dedicated to pharmacokinetic measures computations. An example of HS-TnT Ln(AUC) calculation is provided in online-only Secondary end points were procedural and in hospital complications in the Safety population. Angiographic success was defined as <20% obstruction after the procedure with Thrombolysis in Myocardial infarction (TIMI) grade III at the end of the procedure. Coronary dissections were defined using the National, Heart, Lung, and Blood Institute (NHLBI) criteria . CoronarThe number of patients needed in the study (90 patients in each arm) was calculated on the basis of preliminary results from a non-randomized pilot study conducted on 16 patients treated with clopidogrel (n = 9) or ticagrelor (n = 7) who underwent RA in the University Hospital of Toulouse. Data collection, management and analysis were performed by a dedicated coordinating center . Statistical analyses were conducted in a blinded fashion.t-test or non-parametric Mann–Whitney tests were used to compare continuous variables between the two groups, and the chi-square test or Fischer’s exact test were used to compare categorical variables. Ln(AUC24h) were compared using analysis of variance adjusted for stratification factors . Factors associated with Ln(AUC24h) were studied in the ITT population. For univariate analyses, relationships between Ln(AUC24h) and the subject’s characteristics were studied using Student’s t-tests or ANOVAs for categorical variables and using Spearman correlation coefficients for continuous variables. Multivariable analyses were performed using stepwise backward multiple linear regression. Underlying assumptions of linear regression  were checked. Statistical analyses were performed using Stata Statistical Software, release 10 . Statistical significance was assumed at p value < 0.05.The nature of all reported clinical events was adjudicated by independent physicians who were not involved in the study. Categorical data are presented as numbers and percentages and continuous data as means and standard deviations (or medians and interquartile ranges when skewed). Student’s From November 2015 to April 2018, a total of 180 patients was randomized in the study. Six patients did not have any blood sample after the index procedure, and one patient under tutorship was mistakenly included. Finally, 84 patients in the clopidogrel group and 89 patients in the ticagrelor group were considered in the ITT analysis  were mainly selected in 83.5% of cases. The burr-to-artery ratio was 0.46 ± 0.06 mm. A left main stenosis was involved in the RA procedure in 18.1% of patients. Median duration of RA was 36 (24–60) seconds. Stents were implanted in almost all procedures . Procedural success was achieved in 97.6% and in 97.8% of patients in the ticagrelor and the clopidogrel group, respectively.In the overall population, the incidence of Type 4 MI and myocardial injury according guidelines on the fourth definition of myocardial infarction were, respectively, 72.3% and 99.4%.p = 0.60). No differences were observed concerning troponin release between ticagrelor and clopidogrel groups according to initial diagnosis at admission (As shown in dmission . SimilarIn-hospital cardiovascular events were analyzed in the Safety population (online-only TIRATROP is the first trial comparing ticagrelor with clopidogrel in patients with calcified lesions treated with RA. We failed to demonstrate the superiority of ticagrelor over clopidogrel to limit the extent of myocardial injury during RA procedures. Indeed, our results suggest that ticagrelor has no superior efficacy in the prevention of ischemic complications of RA, such as no reflow/slow flow. Few data are available about the effect of ticagrelor on post PCI troponin rise in stable CAD patients, and results were controversial until the ALPHEUS trial ,8,9. ThiGpIIb/IIIa inhibitor use has also been investigated in RA procedures ,22,23. AHigh sensitivity cardiac troponin measurement is currently the gold standard to detect myocardial cell damage in the bloodstream following PCI, and procedural myocardial injury is frequently observed after PCI even in stable CAD patients ,27. ProgThe large size of the sheath usually used for the ablative device and the use of a transfemoral approach combined with a longer procedural time have been historically associated with a high risk of bleeding. Although this study had inadequate statistical power to detect clinical differences between ticagrelor and clopidogrel, few in-hospital bleeding events were reported, and no differences between both treatment regimens were observed. Potential explanations could be the large use of radial access with reasonable sheath size and the absence of treatment with GpIIbIIIa inhibitors, as planned in the study protocol.In conclusion, this multicenter, randomized trial shows that ticagrelor is not superior to clopidogrel to attenuate troponin release after RA procedures. Moreover, our results suggest that myocardial injury induced by RA is not influenced by the degree of P2Y12 inhibition.The limited size of the cohort may be the cause of the failure to identify clinical differences between clopidogrel and ticagrelor. Larger clinical studies would be of interest, but trials are difficult to implement in such niche procedures. In the present study design, a 300 mg clopidogel loading dose instead of 600 mg should have favored effects of ticagrelor compared with clopidogrel. Despite this dosage, no differences were observed between the clopidogrel and the ticagrelor group in terms of troponin release. Treatment duration according to randomization was limited to hospital stay in the present study. A short treatment period contributes to attenuate clinical discrepancies between arms. One of the main advantages of ticagrelor over clopidogrel is its faster onset of action. As the study includes patients with elective procedures and loading was performed on the evening before the procedure as per study protocol, no conclusions can be drawn on patients needing ad hoc atherectomy. Some protocol deviations were observed, mostly due to the absence of complete adherence to the allocated treatment regimen. However, since the per protocol analysis achieved in 160 patients showed comparable results, we do not believe protocol infringements would have affected final results.