Phoenix dactylifera L.) are rich in sugar and also contain a substantial amount of phenolic compounds. Therefore, date fruits can be used to produce an alternative sweetener, having lower glycemic index than sucrose. This study investigated the effects of extraction and evaporation methods on various properties of the syrups prepared from Barhi dates. Extraction of date juice with the aid of pectinase or cellulase significantly enhanced the production yield, total phenolic content, and antioxidant activities determined by Ferric Reducing Antioxidant Power and Oxygen Radical Absorbance Capacity assays. Syrups prepared without enzyme application had about 6–7 times higher apparent viscosity than those prepared from the enzyme-assisted extracted juices. Vacuum evaporation produced syrups with significantly lighter color and inferior antioxidant properties than open heating. Properties of date syrups prepared with or without enzyme-assisted extraction followed by open heat evaporation were not different. They had a glucose-to-fructose ratio close to 1:1, received good sensory acceptability scores of above 6 on a 9-point hedonic scale, contained a safe level (<40 mg/kg) of 5-hydroxymethyl-2-furfuraldehyde, and exhibited similar glass transition and melting temperatures; while a greater inhibition on α-amylase activity was observed in syrups obtained from enzyme-assisted extraction. The in vivo glycemic measurement revealed that the syrup prepared with the aid of Pectinex and open heating was classified as low glycemic index (GI = 55) and medium glycemic load (GL = 11). Thus, enzyme-assisted extraction of date juice using Pectinex could be used to produce a healthy natural sweetener from low quality date fruits.Date fruits ( The increasing prevalence of non-communicable diseases, particularly diabetes and obesity, has become a major global public health concern. According to the World Health Statistics report in 2022, the global share of deaths attributable to non-communicable diseases was 74%, and the global prevalence of obesity was markedly higher among adults aged 15–49 years ,4,5,6.Phoenix dactylifera L.) is one of the important subsistent crops in many countries. The plant originated from warm desert areas of the Middle East region and North Africa [Date palm  ,18,19,20Phoenix dactylifera L.) of Barhi cultivar were donated by Aura International Co., Ltd. . The fruits were harvested at Khalal maturity stage (120–135 days pollination) from culture-originated female palm trees grown in Kanchanaburi province, Thailand. After harvesting, the fruits were sorted according to the company’s quality specification, which is consistent with the international standard for dates [Fruits of date palm , and cellulase mixture, Viscozyme® L , were donated by Brenntag Ingredients . All chemicals and reagents, unless stated otherwise, were obtained from Sigma-Aldrich .Commercial hydrolytic enzymes, namely pectinase mixture, Pectinex® Ultra SP-L or Viscozyme® L at the enzyme-to-substrate ratio of 50 U/100 g date flesh. The mixture was mixed thoroughly with a magnetic stirrer and placed in a thermostatically controlled shaking water bath at 50 °C, which is the enzyme’s optimum temperature, for 2 h for Pectinex, or 4 h for Viscozyme. Upon completion, the pulp was heated at 90 °C for 5 min in a boiling water bath to inactivate the enzyme, prior to pressing with a press juicer at 1 MPa pressure, and filtering through a double layer cheesecloth to obtain date juice. Conventional extraction of date juice was performed without the application of enzymes by heating the date pulp at 95 °C for 15 min, followed by pressing and filtering, as described earlier. The extraction was conducted in triplicate and the soluble solids yield of each of the obtained juices was calculated from its total soluble solids content (TSS), which was measured using a hand refractometer .The frozen date fruits were thawed, halved, and depitted manually, prior to homogenizing with deionized water at the weight-to-volume ratio of 1:2 using an electric blender  to obtain date pulp. Enzyme-assisted extraction of date juice was performed according to the suitable conditions obtained from our preliminary experiments. The date pulp was treated either with PectinexEvaporation of date juice was performed by open heating or vacuum evaporation, as described elsewhere , to obtapH value was measured at 25 °C based on AOAC method 943.02  using a w) was measured based on AOAC method 978.78 [Water activity  by using a spectrocolorimeter . L* value indicates lightness or brightness; a* value indicates red for positive value and green for negative value; b* value indicates yellow for positive value and blue for negative value. Measurements were conducted in triplicate. The results were also expressed as browning index (BI) to indicate the extent of browning, which were calculated as follows :(3)BI = 1, a*1 and b*1 were the values of date syrup prepared without enzyme followed by evaporation using open heating (CO), and L*2, a*2 and b*2 were the color values of other date syrups.In addition, the total color difference (∆E*) were calculated to determine the difference in color of syrup samples, using the following equation :(5)ΔE* =−1 at constant temperature. Measurements were conducted in triplicate. Apparent viscosity (mPa·s) at the shear rate of 50 s−1 was reported. Flow behavior and consistency indices were determined by fitting the obtained flow curves using the power law model [−1), K is the consistency index (Pa · sn), and n is the flow behavior index.Rheological measurements of syrup samples at room temperature (25 ± 0.1 °C) were carried out according to the previously described methods with slight modifications  using a aw model :(6)τ = KTotal phenolic content (TPC) and antioxidant activities of date syrup samples were analyzed using well-established methods, as described in a previous work . The dat® 800 ELSD detector  and a prevailing carbohydrate column  (AOAC 982.14). Energy content was calculated by multiplying the content of each macronutrient with its caloric content, i.e., 4 kcal/g for protein and carbohydrate, and 9 kcal/g for fat. Analyses was carried out in duplicate of each syrup sample.Nutritional composition of date syrups was analyzed according to the AOAC official methods . MoisturAnalysis of 5-hydroxymethyl-2-furfuraldehyde (HMF) in date syrups was carried out based on the method of AOAC . Syrup sSaccharomyces cerevisiae α-glucosidase . The substrate in both assays was p-nitrophenyl-α-D-maltopentaoside. The enzyme inhibitory activities were determined by measuring the absorbance at 405 nm using a 96-well UV-visible microplate reader, and calculated as a percentage of inhibition:The inhibitory activities of α-amylase and α-glucosidase were investigated using the protocols previously described . The α-agT), which is the temperature, at which inflection point in the specific heat capacity occurred in order to form an amorphous glass, as well as melting temperature (mT), were determined using a thermal analysis software . The temperatures at peak values are reported. Thermal measurements of syrup samples were carried out using a differential scanning calorimeter . The calorimeter was calibrated with indium standards. Samples (3–4 mg) were weighed into aluminum pans, and hermetically sealed. A hermetically-sealed empty aluminum pan was used as a reference. In order to avoid condensation of water, nitrogen gas was used to purge the furnace chamber at 80 mL/min outside and 60 mL/min inside. The thermal scans were conducted from –65 to 160 °C at a heating rate of 10 °C/min . At leasSensory evaluation was performed by 60 untrained panelists aged 18 years old and above, who were recruited from staff and students of Mahidol University to represent the general population who are target consumer of the syrup product. The protocol was approved by the Mahidol University Central Institutional Review Board. Date syrup samples (10 g) were put in clear plastic cups covered with lids and labelled with 3-digit random numbers. Panelists were asked to taste the samples at room temperature together with plain pancakes in a monadic sequential presentation scheme, randomly assigned for each panelist. Each sample was evaluated for appearance, color, odor, consistency, taste, and overall acceptability using a 9-point hedonic scale . Panelists were asked to rinse their mouths with bottled drinking water between date syrup samples .2. Exclusion criteria were abnormal fasting blood sugar ≥100 mg/dL, known diabetes mellitus and related conditions, major medical or surgical events requiring hospitalization within the past 3 mo, being pregnant, breastfeeding, and use of medications affecting glucose tolerance and gastrointestinal functions. Each subject gave written informed consent for the study and were verbally briefed about the assessment. The weights and heights of subjects were obtained following standard procedures.The glycemic index (GI) of date syrup PO was evaluated following the ISO 26642 method . EthicalSalmonella spp., and Staphylococcus aureus to ensure the compliance with microbial standard. The available carbohydrate content in the tested sample was determined by subtracting the carbohydrate content with the dietary fiber content, which were analyzed according to the aforementioned AOAC official methods [Date syrup was prepared under hygienic conditions within 1 wk prior to the experiment, packed in capped glass jars, and stored at room temperature. The syrup was tested for aerobic plate count, yeasts and molds,  methods .Each subject completed the set of four weekly visits, including three visits to obtain the incremental area under the curve (IAUC) for the reference food (anhydrous glucose) and one for the testing date syrup in a random sequence. The day before the study, each participant was informed refrain from vigorous exercise and consumption of beverages containing alcohol or caffeine. The subjects were asked to consume a standard dinner and observe a 10–12 h overnight fast preceding the test. On the test day, an intravenous catheter was inserted into an antecubital vein for blood sampling and a fasting blood sample was drawn. Subjects were required to consume 200 mL of reference food or test food solution containing 50 g of available carbohydrate, i.e., 50 g of anhydrous glucose or 70.16 g of date syrup, which was prepared by dissolving the food in drinking water. Each subject was asked to finish the solution within 10 min, followed by 100 mL of drinking water. Subjects are required to remain sedentary during 3 h of the experiment, and were prohibited from eating and drinking until the end of the session.Blood samples were taken at 15, 30, 45, 60, 90, and 120 min after complete ingestion of the meal. Blood samples were centrifuged to separate plasma, and the plasma glucose (mg/dL) was analyzed by the glucose oxidase method using a commercial kit with an automatic biochemistry analyzer . The IAUC for reference food and date syrup was calculated using GraphPad Prism 5.01 software . The GI value of date syrup was calculated from IAUC of the test food and the average IAUC (n = 3) for the reference food in each subject, as follows:The glycemic load (GL) was calculated from the amount of available carbohydrates in a standard serving of syrup, i.e., 30 g or 2 tablespoons, and the GI.p < 0.05.The data was analyzed by IBM SPSS Statistics for Windows Version 18.0 . The data was presented as means and standard deviations, except that chemical composition was reported as means of duplicate analysis. Mean difference was carried out by independent sample t-test or one-way Analysis of Variance (ANOVA) and the differences between means were distinguished using Duncan’s Multiple Range Test at The date juice extracted without the addition of enzymes had the lowest soluble solids yield (54.27 ± 5.89%). The soluble solids yield obtained from Pectinex- and Viscozyme-assisted extractions were 71.39 ± 0.66% and 73.29 ± 1.22%, respectively, which were significantly higher than that extracted in the absence of enzymes. There was no significant difference between the soluble solids yield of extraction using Pectinex and Viscozyme. Enzyme-assisted extraction increased the juice extraction efficiency by hydrolyzing the structural polysaccharides in plant tissues, resulting in the tissue softening. Such phenomenon led to the greater release of intracellular components, particularly soluble substances, such as sugars and organic acids, hence the soluble solids yield of the obtained juice increased. Several researchers have reported that pectinolytic and cellulolytic enzymes enhanced the liberation of sugar and phytochemical compounds during the extraction, resulting the improved physico-chemical and functional properties of the extracted juice ,32.The production yield of date syrup depended largely on the juice extraction method . Enzyme-w of all syrup samples prepared using different juice extraction and evaporation methods was about 0.60, owing to their similar TSS. It is known that food products with intermediate aw of 0.6–0.7 are highly susceptible to Maillard browning reaction [All date syrups had pH values ranged from 4.80–5.39, which were categorized as low acid food. Syrups prepared from any enzyme-extracted juices had pH values of lower than 5, which were lower than those prepared without enzyme. The pH of date syrups subjected to different evaporation methods was similar. The more acidic syrups produced from enzyme-extracted juices was due to the significantly increased amount of organic acids being liberated from the fruit tissue during enzyme-assisted extraction . The aw reaction , especiaColor is one of the quality indices of syrups, which is often associated with the chemical composition and content, as well as their changes upon the processing. Photographs taken of date syrups prepared using different extraction and evaporation methods are presented in The BI of syrups reflected the extent of the browning reaction, which occurred during juice extraction and evaporation. Syrups obtained from vacuum evaporation had lower BI than those evaporated by open heating. Such differences contributed to their different color values and were visually noticeable from the syrups’ brown color. It was plausible that the harsher condition (higher temperature and longer time) of open heating, as well as the exposure to oxygen, led to the greater extent of browning reactions . Thus, tRheological properties affect the flow characteristics, particularly the pourability and spoonability, of honey and honey-like products . The rhe−1 was compared because such shear rate can represent the oral processing. Overall, date syrups prepared without enzymes had up to 10 times higher viscosity than those prepared with enzyme application for date juice extraction. Pecinex-assisted extraction gave syrups a higher viscosity than Viscozyme, regardless of the evaporation conditions. The evaporation method less affected the viscosity of the obtained syrup than the extraction method. When the syrups evaporated under different conditions were compared, it was found that syrups extracted without enzyme and evaporated with open heating were more viscous than its counterpart evaporated under vacuum. For Pectinex and Viscozyme-extracted juice, the evaporation condition did not affect the viscosity of the obtained syrups. The lower apparent viscosity of the syrup produced with the aid of enzymes occurred from the degradation of the structural polysaccharides naturally present in the fruit cell wall and the reduced complex interactions among soluble sugars, pectin substances, and suspended solids [−1. On the other hand, date syrups prepared with Pectinex and Viscozyme were honey-like (351–1750 mPa·s) and nectar-like (51–350 mPa·s), respectively.Viscosity is important in the production and the application of syrups in food. Highly viscous syrups would be difficult to pour and mix into the food, while syrups with too low viscosity would be too runny to cling on the top of the food surface. Apparent viscosity at the shear rate of 50 sd solids . Consided solids , date sy2) for the fitted curves of all samples was 0.9718–0.9997. The flow behavior index of date syrup samples was 0.40–0.88, indicating that all syrups were non-Newtonian fluid. In addition, their flow curves  in all syrup samples assured that the Maillard reaction could occur during syrup production. Nevertheless, the more reducing sugars in PO and VO did not correspond to a reduction in the extent of the Maillard reaction, as evident in their lower BI . On the The key enzymes related to diabetes, namely α-amylase and α-glucosidase, are important in the hydrolysis of polysaccharides into monosaccharides, which can be absorbed into cells. Inhibition of those enzymes might retard the digestion of carbohydrates and consequently delay the increase in the blood glucose level. In this study, the inhibitory activities toward the two enzymes were assessed using 50 μL date syrup in a 200 μL assay. PO provided a four-fold lower α-amylase inhibitory activity than VO and CO . BetweenThermal properties are widely used to evaluate thermal stability of syrup and honey. Glass transition and melting behavior of date syrups were determined from DSC thermograms . For allgT and mT. The gT value of syrups depends largely on the composition of sugar and the water content [gT value of syrup. It is plausible that the gT value of CO was the lowest among other samples because it had the highest moisture content, although the difference was not significant. The mT of all date syrup samples were between 127 and 134 °C. The melting peak of CO was broader and less intense than PO and VO. It has been reported that the melting curve of honey depended on its chemical composition and thermal history [The onset of glass transition for all date syrups took place at −57 °C and reached its peak between −54 and −55 °C . Such va content ,57. The  history .Sensory attributes of date syrups, including appearance, color, odor, consistency, and overall acceptability, were evaluated using a 9-point hedonic scale. The panelists were aged 24–58 years old with the average age of 36.60 ± 11.22 years. It has been reported that people in the 20–59 years age group account for more than half of the Thai population, and they are major consumer group of syrups and spreads in Thailand [The sensory acceptability scores for all attributes of date syrups ranged between 6 and 7, which was like slightly to like moderately . There wTaking all the results into account, PO had the greater antioxidant properties and the stronger inhibition on carbohydrate digestive enzyme than the syrup prepared without the aid of enzymes. Although most of the properties of PO were comparable with VO, the Pectinex-assisted juice extraction took a shorter time to reach its maximum soluble solids yield than Viscozyme. Therefore, only the date syrup PO, which was prepared using Pectinex-assisted extraction of juice followed by evaporation using open heating, was selected for further investigation.Due to the unusually low blood glucose level obtained in the oral glucose tolerance test, one out of 12 participating subjects was excluded. Finally, 11 healthy subjects  aged 23–34 years with normal BMI were included in further analyses . In all The GI value was calculated from the IAUC of a tested food’s blood glucose response curve and reference food. GI describes the rate that carbohydrate is converted into glucose and absorbed. It was found that the date syrup PO was classified as low GI (55.13 ± 17.55), according to American Diabetes Association . When GLThe GI values of date syrups in this study were slightly higher than that previously reported for Barhi date fruits from the United Arab Emirates (GI = 49.7) . It coulThis study investigated various properties of date syrups prepared using different methods for juice extraction and evaporation. It was evident that the juice extraction method impacted the production yield, rheological properties, antioxidant properties, carbohydrate composition, and inhibitory activities on carbohydrate-digestive enzymes of the obtained syrups, while the evaporation method had a strong influence on the syrup color. However, such differences did not affect the HMF content, thermal properties, and consumer sensory acceptability of the syrups prepared with different extraction methods followed by evaporation using open heating. The results from the in vivo study indicated that the date syrup prepared from juice extracted with the aid of Pectinex followed by evaporation using open heating were low GI and medium GL. Thus, enzyme-assisted extraction of date juice using Pectinex could be an option to produce a healthy natural sweetener from date fruits, which would add the value of low-quality date fruits and help to reduce food loss in the dates supply chain. Further analyses should be conducted to elucidate the bioactive compounds and physiological effects of the syrups.


Technological advancements in accelerator-based neutron sources have allowed for a more accessible and feasible study of Boron Neutron Capture Therapy (BNCT). Accelerator-based BNCT centers are being developed world-wide, and recent research is showing the potential in treating cancers. There are ongoing efforts to initiate Canadian contributions to BNCT research and the development of a Canadian center. We surveyed radiation oncologists and medical physicists in Canada to study their perception, understanding, and support for BNCT. The results of this survey guide Canadian contributions by identifying knowledge gaps and collaborative opportunities that support the success of this innovative cancer treatment in Canada.Background: Boron Neutron Capture Therapy (BNCT) is an emerging radiotherapy. There are ongoing efforts to develop a Canadian accelerator-based BNCT center. However, it remains unclear how Canadian radiation oncologists (RO), medical physicists (MP), and their trainees perceive BNCT and its impact on radiation oncology as a discipline. Methods: A survey was created to explore the knowledge of BNCT, its clinical role, and the support for Canadian research. It was distributed through the Canadian Association of Radiation Oncology (CARO) and the Canadian Organization of Medical Physicists (COMP). Results: We received 118 valid responses from all 10 provinces, from 70 RO (59.3%) and 48 MP (40.7%), including 9 residents. Most knew of BNCT and its indications (60.2%). Although many were unaware of the reasons behind early failures (44.1%), common reasons were a lack of clinical trials and an inaccessibility of neutron sources (42.4%) as well as reactor unsuitability (34.7%). Additionally, 90.6% showed definite (66.9%) or possible (23.7%) support for Canadian BNCT research, while 89% indicated a definite (56.8%) or possible (32.2%) willingness for BNCT referrals. Conclusions: Most ROs and MPs supported Canadian BNCT research and would refer patients. However, limited awareness and a lack of experiences remain a challenge. Educational sessions are needed to realize this innovative cancer treatment in Canada. As oncological diseases continue to be a leading cause of morbidity and mortality in Canada, efforts continue to discover, validate, and refine existing and emerging treatment options . Boron NBoron carrier agents, such as sodium borocaptate (BSH) and boronophenylalanine (BPA), are administered to patients to create a higher concentration of boron in tumor cells compared to normal tissue ,3,4. An Compared to standard radiotherapy, BNCT’s advantage is its selectivity toward cancer cells, minimizing the risk of side effects to normal and radiosensitive tissue. Its efficacy depends on an appropriate boron concentration in tumor cells and neutron beam energy characteristics . Early BIts theory was proposed in 1936 and tested in 1951 in the Brookhaven National Laboratory (BNL) and Massachusetts Institute of Technology (MIT) labs with limited success ,8. In thThe previous reliance on nuclear reactors posed significant barriers to research and clinical applications. Challenges arose due to high costs, unsuitable infrastructure for hospitals and patient use, uranium fuel’s environmental impacts, and broad neutron beam characteristics ,12. CanaThe need for accessible neutron sources propelled advances in a compact accelerator-based neutron source (CANS) which eventually succeeded ,14,15,16The development of CANS renewed interest in BNCT and facilitated the development of AB-BNCT centers in various countries such as Japan, the UK, China, Finland, and Russia ,20,21. IDespite global interest in BNCT research, Canada has yet to play a major role in this field. To support Canadian contributions, a Canada Foundation for Innovation (CFI) 2023 Innovation Fund is underway (Project number: 42891) to develop a low-cost prototype Canadian compact accelerator-based neutron source (PC-CANS) ,24,25. THowever, there has been limited exploration of the recent perspectives and of the knowledge status of key stakeholders that could potentially be involved in future BNCT research and therapy. Such perspectives are important to account for in the context of recent technological advancements and innovation.Our objective is to explore the perceptions and understanding of BNCT amongst Canadian radiation oncologists (RO), medical physicists (MP), and their resident trainees. Specifically, a survey was distributed to explore the following: (1) understanding of BNCT’s history and recent developments, (2) support towards Canadian BNCT research, and (3) recognition of clinical applications of BNCT.We hypothesized varying perceptions ranging from support towards BNCT, considering its recent developments and global uptake, in addition to some hesitations due to limited large-scale clinical data. The results of this survey guide Canadian contributions by identifying knowledge gaps and collaborative opportunities that support the success of this innovative cancer treatment in Canada.After an in-depth scientific review of the literature, a survey was created using Google Survey. The survey was distributed through two national organizations, i.e., the Canadian Association of Radiation Oncology (CARO) and the Canadian Organization of Medical Physicists (COMP). Informed consent was obtained prior to participation in the study. This study was approved by the Windsor Regional Hospital Research Ethics Board (REB #22-429) as well as the Board of Directors of both CARO and COMP.The survey was open to collect responses between 24 January 2022 and 23 May 2022. It was voluntary, without compensation, and participants remain anonymous. There was a total of 17 items, divided into 3 domains: (1) eligibility, (2) demographics, and (3) specific knowledge of BNCT and utilization. For some questions, respondents had the ability to offer their own responses, in addition to selecting existing options. Respondents also had the opportunity to offer final comments or opinions in the last item of the survey. There were no excluded responses. The results were analyzed using descriptive statistics and IBM SPSS Statistics, Version 28.0.1.1(14).Eligibility is limited to ROs with an independent/academic license, board-certified MPs, or residents in a formal residency-training program. A total of 118 respondents were collected: 53.4% (N = 63) were radiation oncologists, 39% (N = 46) were medical physicists, while 5.9% (N = 7) were residents in radiation oncology and 1.7% (N = 2) were residents in medical physics. There were no missing answers throughout the survey.As of May 2022, the survey was distributed by CARO to 305 ROs, 56 MPs, and 231 residents . It is known that many of CARO’s MP members also have a COMP membership. At the same time, COMP has distributed the survey to 563 MPs and residents, but we do not know how many are foreign members or from other industries and not working in radiation oncology in Canada. Due to the limitation of defining domestic and international residents, it is impossible to know the real number of Canadian residents. However, based on the current Canadian postgraduate training positions, we estimated a maximum number of 105 Canadian residents who received the survey . We are also unaware of the numbers of COMP’s Affiliate Members in other organizations and industry who are unlikely to be interested in our BNCT survey. As a result, we estimated the number of MP working or training in radiation oncology to be 50% of that of RO . Based on these assumptions, the response rates were estimated to be 21% for RO, 31% for MP, 7% for RO residents, and 10% for MP residents.Most respondents were between 35 and 45 years old  and male . Respondents’ practice region included all 10 Canadian provinces, with a majority from Ontario 45.8% (N = 54) followed by Quebec 18.6% (N = 22). Furthermore, most respondents reported being in practice for 10–20 years  followed by staff in practice for over 20 years . A full display of respondents’ demographics is displayed in Regarding knowledge about BNCT, the prevailing answer was that participants had previously heard about it and know about its indications and rationale . Specifically, 44.3% of the RO group reported not knowing about BNCT (N = 31) compared to 18.8% of MPs (N = 9).Only 4 respondents (3.4%) reported being involved in the CFI 2023 IF application to make BNCT available in Canada. A minority reported having encounters with BNCT in the form of participating in treatments  or referring patients to BNCT .The additional responses that were offered mostly involved MPs indicating prior experiences in neutron physics technology development  and research activities . Additionally, 2 RO physicians reported hearing about it once or recalling it from training .When probing for perceptions on reasons behind the lack of success of early BNCT research between the 1950s and 2000 in nuclear reactors, participants most frequently selected ‘I don’t know’ as a response . The second-most selected option referred to a lack of large clinical trials related to the limited availability of neutron sources or BNCT centers .When comparing differences between RO and MP perceptions, the biggest difference was found in the number of respondents selecting ‘lack of precision in measuring boron concentration in the patient’ as an option. Specifically, 41.7% of physicists (N = 20) selected this option compared to 20% of oncologists N = 14; .Participants also had the ability to offer responses, most commonly pointing towards a lack of infrastructure  such as “no availability of reactors” and “no linac-based neutron sources” .For the four questions in this section, only radiation oncologists’ answers were analyzed to accurately reflect the reality of clinical decision making (N = 70). In addition to the listed choices, respondents had the ability to offer additional written responses, detailed in The cases included recurrent and unresectable tumors following maximal dose chemoradiation. The most common treatment recommendations selected were as follows: palliative chemo such as temozolomide  for GBM, supportive care only  for malignant meningioma, palliative chemotherapy  for head and neck cancer, and fourth line targeting therapy or immunotherapy  for localized unresectable malignant melanoma.Out of seven listed options, BNCT was the sixth most rated option for glioblastoma , in addition to malignant melanoma and meningioma . For head and neck cancers, BNCT was the least popular option compared to the other listed options .This section of the survey included three questions regarding recent significant milestones in BNCT history to further understand the knowledge status of RO and MP in regards to recent developments . The surRespondents were asked for their interest in supporting Canadian research efforts, their perspectives on referrals, and their recognition for BNCT’s clinical role, demonstrated in When asked whether Canada should join interdisciplinary global research efforts to move BNCT towards a clinical technique, 66.9% (N = 79) of the total respondents agreed. Additionally, 23.7% (N = 28) selected ‘maybe’, meaning they would possibly support BNCT research efforts. A minority of respondents  disagreed with joining research. For this question, overall responses between MPs and ROs were comparable, as 68.8% (N = 33) of physicists and 65.7% (N = 46) of oncologists similarly agreed to join research efforts.As for the willingness to refer cancer patients who failed all other treatments, should there be a low-cost AB-BNCT facility in Canada, a total of 56.8% of respondents (N = 67) agreed, while 32.2% (N = 38) indicated that they may refer. Alternatively, 10.2% (N = 12) would not refer. Comparing between groups, slightly more radiation oncologists would refer to BNCT  compared to physicists , while more physicists  selected ‘maybe’ compared to oncologists The last question asks for possible clinical scenarios that could be considered a standard indication for BNCT. Data analysis focused only on the RO respondents (N = 70) to best reflect the reality of clinical practice, as most MP provided invalid answers suggesting that they would not typically make such decisions. However, only one physicist agreed (GBM). Two oncologists (2.9%) suggested “advanced sarcoma after debulking surgery, possibly hypernephroma with 10BPA” and “Recurrent HNC, GBM, malignant meningioma, melanoma that are unresectable after maximal dose EBRT”. In contrast, 42.9% (N = 30) of RO physicians suggested the possibility of a standard indication but did not offer examples, while 47.1% (N = 33) disagreed.Participants had the ability to anonymously offer additional comments to express overall opinions on BNCT. Comments included hesitations and enthusiasm towards BNCT, interest in research, lack of awareness of BNCT, and practical considerations of BNCT research.Some respondents expressed reservations: the premise of using BNCT after radiotherapy “is a bit flawed [and] would have to be better supported”. Some expressed hesitations due to the slow progression: “[I’m] wary about investing time and effort in developing a technique that hasn’t received substantial uptake despite decades of existence” and “we’ve pushed the dose confinement paradigm for the last 70 years without seeing a huge improvement in cure although toxicity has been greatly reduced… I think the future lies with targeted immunotherapy…. I am prepared to keep an open mind, but I would need convincing to put research dollars into this enterprise”. More specifically, one voiced concern about the limited knowledge on “an optimal Boron compound [and] the optimal administration [and] resulting tumor/tissue uptake”.Alternatively, affirming the Canadian potential to join and succeed in BNCT research, respondents offered the following: “I think we should move forward with BNCT; often the introduction of a new technique serves as a catalyst for new discoveries” and “BNCT shows interesting applications in advanced forms of cancer that have limited curative options. I’m very happy to see a Canadian initiative to bring this modality!” Another highlighted Canada’s capabilities, saying, “we have knowledge, the resource, and clinical science background. We should move forward.”Regarding the nature of BNCT research, some commented on Canada’s “expertise to handle a project of this nature” and “capabilities of performing comprehensive clinical trials with the appropriate number of patients.” A comment noted BNCT as a “purely investigational therapy,” but it is still worth “participating in developing and evaluating promising investigational therapies.” Another commented, having “missed the opportunity to develop Proton Therapy, [Canada needs to] catch up the other particle radiation therapy research to join the international pioneers to advance our specialty and improve cancer patients’ outcome.”Furthermore, there were suggestions of the need to consider “travel, accommodation and incidental costs” as a potential barrier for referral, especially for patients in rural areas. Moreover, given the multidisciplinary nature of such research, the importance of “collaboration between high-level radiation oncologists, medical physicists, radiobiologists, and medical/radiation chemists” was highlighted, requiring “institutions [capable of] large scale clinical trials support,” such as those “located in regions of large patient populations.”Lastly, there were an indication and an interest for continued education of BNCT in academic circles: “I am not familiar with it, but I can see the benefit if properly implemented” and “I know next to nothing about BNCT. It would be great to see some talks on the subject at the next COMP meeting.”This survey explores the perspectives and the knowledge status of Canadian medical physicists and radiation oncologists regarding BNCT to guide future Canadian contributions.Our results show that the majority are aware of BNCT and its indications (60.2%) and attribute the lack of success of early BNCT studies to limited trials (42.4%) and neutron source inaccessibility (34.7%). However, a large proportion do not know about BNCT (33.9%), which aligns with 44.1% not knowing reasons behind its failure and only 5.1–29.7% correctly identifying recent developments and global practices. Overall, 90.6% showed definite (66.9%) or possible (23.7%) support for Canadian BNCT research, while 89% indicated a definite (56.8%) or possible (32.2%) willingness for BNCT referrals.In the context of ongoing efforts for Canadian contributions to BNCT, the survey results demonstrate support for a PC-CANS to support AB-BNCT research and clinical application ,24. ThisA majority (89%) of respondents showed definite (56.8%) or possible (32.2%) willingness to refer patients to Canadian BNCT facilities despite a small minority having direct interactions with BNCT referrals . Additionally, two comments noted barriers and access to centers as important considerations in the context of referrals, especially for patients in rural areas. This concern is consistent with the previous literature indicating barriers to access to radiotherapies in Canada as being patient age (34.7%), distance to centers (30.7%), wait times 29.3%), and provider factors such as a lack of understanding about the use of radiotherapy (21.6%) [.3%, and The overall willingness for BNCT referrals aligns with the recommendations of BNCT by 15.7–18.6% of ROs in the provided clinical scenarios . This is supported by clinical trials showing BNCT’s clinical potential in treating cancers; a further review of clinical applications can be found in Malouff et al. (2021) and Moss (2014) . AlthougFor example, when asked about barriers limiting BNCT’s success, survey results indicated that limited clinical trials and infrastructure unsuitability were weighted more heavily than planning systems and concerns with boron agents and dosimetry. This is consistent with assertions in the literature highlighting the essential role of clinical trials and neutron source accessibility to sustain interest and progress in BNCT and their lack thereof as the biggest weakness limiting BNCT ,19.Despite significant progress in the field of BNCT, research efforts continue to optimize BNCT’s delivery and outcome. Continuing areas of research focus on treatment planning and optimized delivery of existing or new boron carrier agents. For example, efforts continue to further understand second-generation BPA’s and BSH’s biodistribution profiles ,31. MoreA recurring theme throughout the results points to limited knowledge on BNCT’s current status, reasons for a lack of success, and recent developments and applications. For example, 33.9% indicated they do not know about BNCT, which was more pronounced in RO (44.3%) compared to MP (18.8%). Additionally, 44.1% indicated that they did not know the reasons behind the lack of success of early BNCT studies, and only 5–29.7% were able to correctly identify recent developments and BNCT practices. This is also supported by the minority who have had direct interactions with BNCT through treatment observations (1.7%) and participation in BNCT treatments (1.7%) or referrals (0.8%).The literature has also suggested that the lack of awareness of neutron therapies from the public and providers are related to negative perceptions surrounding nuclear reactors and radiation . SpecifiCollectively, our survey results give quantitative confirmation on the proposed limited awareness of BNCT, particularly amongst Canadian radiation oncologists and medical physicists. This would have to be considered in the context of Canadian research initiatives and building of an AB-BNCT facility and point towards the value of educational activities ,24.There are some limitations in this survey. The results may be susceptible to bias recruitment, as those most interested in BNCT may be more inclined to respond to the survey and represent support. Additionally, despite overall representation from all 10 Canadian provinces, most respondents were from Ontario (45.7%) and Quebec (18.6%). Although Ontario and Quebec are the most highly populated provinces, which have 61% of the Canadian population, more feedback from other provinces would further affirm if such notions are common and widely held throughout Canada.With recent technological advancements in accelerator-based neutron sources allowing for accessible AB-BNCT centers, there is renewed global interest in BNCT research. The results of this survey demonstrate that most Canadian ROs and MPs support Canadian BNCT research efforts and would refer patients to a Canadian BNCT center. The implications of such results encourage Canadian participation in BNCT research and the construction of the first Canadian AB-BNCT facility. However, the limited knowledge about BNCT poses a challenge and highlights the value of educational sessions about BNCT to successfully realize this goal.


The goal of this study is to develop a fully automated segmentation and morphometric parameter estimation system for assessing abnormal corneal endothelial cells (CECs) from LASER in vivo confocal microscopy (IVCM) images.First, we developed a fully automated deep learning system for assessing abnormal CECs using a previous development set composed of normal images and a newly constructed development set composed of abnormal images. Second, two testing sets, one with 169 normal images and the other with 211 abnormal images, were used to evaluate the clinical validity and effectiveness of the proposed system on LASER IVCM images with different corneal endothelial conditions, particularly on abnormal images. Third, the automatically calculated endothelial cell density (ECD) and the manually calculated ECD were compared using both the previous and proposed systems.2, 32.18 ± 6.70% and 56.23 ± 8.69% for the normal CEC testing set and 83 cells, 1450 ± 656 cells/mm2, 34.87 ± 10.53% and 42.55 ± 20.64% for the abnormal CEC testing set. Furthermore, for the abnormal CEC testing set, Pearson’s correlation coefficient between the automatically and manually calculated ECDs was 0.9447; the 95% limits of agreement between the manually and automatically calculated ECDs were between 329.0 and − 579.5 (concordance correlation coefficient = 0.93).The automated morphometric parameter estimations of the average number of cells, ECD, coefficient of variation in cell area and percentage of hexagonal cells were 257 cells, 2648 ± 511 cells/mmThis is the first report to count and analyze the morphology of abnormal CECs in LASER IVCM images using deep learning. Deep learning produces highly objective evaluation indicators for LASER IVCM corneal endothelium images and greatly expands the range of applications for LASER IVCM. Normal corneal endothelial cells (CECs) form regular endothelial mosaics of hexagonal cells of approximately the same size with well-defined cell boundaries. The corneal endothelial cell density (ECD) decreases  with age ; the mosThe three parameters commonly used to address such irregularities are the ECD, percentage of hexagonal cells (HEX), and coefficient of variation in cell area (CV). The most common method for measuring these parameters in the clinic is specular microscopy. However, this technique requires a regular, smooth endothelial surface for acquiring high-quality images; although this is the norm in healthy corneas, an abnormal corneal endothelial layer will have fewer CECs, a reduced HEX and cells with abnormal intensity patterns, leading to multiple inconsistent manual analyses of the images for properly assessing the endothelial layer. When the CECs are moderately abnormal , specular images of these cells are prone to low contrast, high noise levels, and blurred cell boundaries. Moreover, many recent studies have shown a lack of agreement among different automatic built-in specular microscopy software programs and sometimes an overestimation of the ECD with automatic segmentation relative to manual segmentation, suggesting that the automatic results should be used with caution –9.LASER in vivo confocal microscopy (IVCM) is a high-resolution, high-speed, digital confocal laser scanning microscope technique that permits in vivo investigations of the cornea. Due to its high resolution, LASER IVCM can be used to identify abnormal CECs. However, the Heidelberg Eye Explorer  of the HExisting fully automated segmentation and quantification systems for abnormal CECs mainly involve the use of specular microscopic images , 12. In system_normal) [system_normal was also conducted in this study. This is the first attempt using deep learning to calculate the ECD, HEX and CV of abnormal CECs from LASER IVCM images.In a previous study, our team developed a fully automated segmentation and quantification system for normal LASER IVCM images  . On LASEIn this prospective study, images of CECs were acquired using a LASER IVCM system . The specific steps of LASER IVCM image acquisition have been described in a previous article . ScanninBoth the normal and abnormal groups were diagnosed by an experienced ophthalmologist (JH) at Peking University Third Hospital from April 2020 to January 2022. For the normal group: potential subjects were excluded from the study if they had undergone previous corneal or ocular surgery, had any ocular pathology and keratopathy, or had chronic use of topical ocular medications. For the abnormal group: patients with acute angle closure or chronic open-angle glaucoma, uveitis, keratitis, and eye surgeries  were included in this study; potential subjects were excluded from the study if the CEC images could not be counted. One hundred and seventy-six patients were included as the abnormal group (randomly split into development and testing set) and 24 patients were excluded.2, an average CV of 36% and an average HEX of 52%. The corresponding parameters for the 132 abnormal LASER IVCM images were 28 cells, 711 cells/mm2, 42% and 23%, respectively. This shows that the abnormal LASER IVCM images had fewer cells, a lower cell density, a higher variation in cell size and more nonhexagonal cells.To develop the automated system, a development set containing 231 LASER IVCM images from 156 patients was used. The 231 LASER IVCM images consisted of 99 normal LASER IVCM images (99 eyes of 99 patients) from a previous work  and 132 The proposed system was tested on two other testing datasets, namely, the normal CEC testing set and the abnormal CEC testing set. We used the testing set from a previous work  but exclFor the input LASER IVCM images, a cell segmentation network was established to generate probability images of the cell edges, which were then subjected to a series of postprocessing steps to produce the final segmentation images, from which the automated morphometric parameters could be calculated. The entire pipeline of the proposed system is presented in Fig. To train the cell segmentation network, the development set was randomly divided into a training set  and a validation set , as shown in Fig. After obtaining the cell edge probability images, a series of postprocessing steps were conducted to produce the final segmentation images . Brieflysystem_normal with the abnormal testing set were compared with the paired-samples t test. All tests were two-tailed with P < 0.05 was considered statistically significant. Bland-Altman analysis was used to evaluate the agreement between the automatically and manually calculated ECDs. The area under the receiver operating characteristic curve (AUC), sensitivity and specificity were calculated based on the probability output images and the binary target images to evaluate the performance of the proposed cell segmentation network. The relative error between the automatically calculated morphometric parameters and the corresponding manually calculated values was also calculated to evaluate the reliability of our morphometric parameter estimation system.Statistical analysis was performed with SPSS 18.0 . For the two testing sets, the correlation between the automatically and manually calculated ECDs was examined using the Pearson test. The ECDs estimated by the proposed system and 2 and 821 cells/mm2, respectively. The average relative errors of the number of cells, ECD, CV and HEX for the 20 normal images were 16.44%, 6.92%, 13.93% and 13.48%, respectively, while the corresponding values for the 20 abnormal images were 16.48%, 19.36%, 22.04% and 45.88%, respectively. The above results show that (1) the abnormal images had a much lower number of cells and lower cell density than the normal images, indicating that the abnormal corneal endothelial condition in our study was very severe; (2) it was more challenging to accurately estimate the morphometric parameters for the abnormal images; and (3) when the segmentation results were inconsistent with the manual labels, the estimations were more easily affected for images with a lower number of cells, especially the estimations of HEX.Although the validation set (40 images) was generated randomly from images from the development set, we ensured that it included 20 normal LASER IVCM images and 20 abnormal LASER IVCM images. The proposed cell segmentation network achieved an AUC of 0.9436, sensitivity of 0.6483 and specificity of 0.9504. The average relative errors of the number of cells, ECD, CV and HEX between the automated values and manual values were 16.46%, 13.14%, 17.99% and 29.68%, respectively. When analyzing the normal and abnormal LASER IVCM images separately, we found that based on manual calculation, the average number of cells for the 20 normal images and 20 abnormal images in the validation set was 139 cells and 37 cells, respectively, and the average ECDs were 2602 cells/mmP = 0.055 > 0.05) and 0.9447 for the abnormal CEC testing set . The 95% limits of agreement between the manually and automatically calculated ECD were between 329.0 and − 579.5  and 0.9220 for the abnormal CEC testing set . The 95% limits of agreement between the manually and automatically calculated ECDs were between 614.6 and − 463.1 (concordance correlation coefficient = 0.91) for the abnormal CEC testing set. Comparing the above results of system_normal with those of the proposed system in this study, we can see that the proposed system (1) yields a substantial 0.0227 improvement in the correlation between the ECDs for abnormal images but a slight 0.0021 reduction in the correlation between the ECDs for normal images; (2) yields a 0.02 improvement in the concordance correlation coefficient between the ECDs for abnormal images; and (3) is more effective in estimating cell density for both normal and abnormal images.The inclusion of abnormal LASER IVCM images in the development set will be very helpful for expanding the application scope of our system in clinical trials, where such abnormal cases more urgently require an accurate diagnosis. To demonstrate this point, we also evaluated system_normal and the manually calculated ECD was 0.0966 for the normal CEC testing set and 0.1522 for the abnormal CEC testing set. This also shows the effectiveness of the proposed system in estimating cell density in LASER IVCM images with widely varying ECDs. In each image, the relative error tended to decrease as the ECD increased  a single image in less than 1 s when run on a 12 GB NVIDIA Tesla K80 GPU and in less than 3 s on a 3.20 GHz Core i7-8700 CPU with 16 GB of RAM.We developed a robust, accurate, fully automated method for estimating the ECD and morphometric parameters from LASER IVCM images in patients with varying severities of abnormal CECs. This is also the first deep learning system to evalute abnormal LASER IVCM images.system_normal, and the concordance correlation coefficient was improved to 0.93 . The proposed system thus clearly outperformed system_normal in the abnormal CEC testing set. Additionally, when the manually calculated ECD was under 1500 cells/mm2, there was a significant difference between the proposed system and system_normal. This phenomenon shows that the proposed system achieved an improved capability in recognizing cells in abnormal CEC images. In summary, the proposed system shows significantly improved performance in the abnormal testing set and perfectly complements the deficiencies of our previous system. This large benefit could help the automated system be applied in actual routine clinical work and extend the range of applications for LASER IVCM images.For the abnormal CEC testing set, the Pearson’s correlation coefficient between the automatically and manually calculated ECDs was improved to 0.9447 using the proposed system from 0.9220 with In Fig. Previously, U-Net had shown promising results in cell segmentation via a delineation of the cell borders. Fabijańska demonstrated further proof via the high performance and accuracy of a U-Net-based learning approach for normal specular corneal endothelial images . CurrentOur system should be further confirmed under cross-validation experimental configuration. In future studies, images should be obtained for both monocentric and multicenter validation of our system. Furthermore, the estimations of morphometric parameters obtained using the proposed system should be tested with large-scale clinical trials.This is the first report to count and analyze the morphology of abnormal CECs in LASER IVCM images using deep learning. We demonstrated that CNNs can be used to recognize LASER IVCM images with high noise levels and low quality. Artificial intelligence-based recognition can produce more objective evaluation indicators for LASER IVCM corneal endothelium images and greatly expands the range of applications of LASER IVCM in the field of ophthalmologic operations, such as post-DSAEK.


Fractures of the femoral neck account for less than 1% of pediatric and adolescent fractures. Due to the high incidence of complications, and the age of the patients, the choice of fixation approach remains controversial among orthopedic surgeons. This study aimed to evaluate the postoperative outcomes and complications of femoral neck fracture in adolescents with open physis, following transphyseal fixation using a combined cannulated cancellous screw and Kirschner wire fixation.Data of 19 patients aged between 12 and 19 years from January 2010 to January 2021 were retrospectively studied. The follow-up period was 1–11 years (5.83 ± 3.76 years). The variables of interest including demographic and clinical variables , postoperative outcomes, and complications  were analyzed. The assessment of the hip function was done on the final follow-up using the Ratliff scoring system.There was a male predominance of 76%; the mean age was 16.14 ± 1.57 years and the most frequent mechanism of injury was fall from a height. Delbet type II and III were the most encountered. The mean intraoperative time was 54.71 ± 7.85 min, the LOS was 8.34 ± 1.81days, and the time to surgery was 2.60 ± 1.16 days; the fracture healing time was 3.31 ± 1.04 months. The postoperative complications encountered were coxa vara osteoarthritis, spontaneous dislocation, and neck shortening. Clinical assessment revealed good results in 89% of patients and fair results in 11% of patients.Transphyseal fixation using cannulated cancellous screw combined with Kirschner wire in our patients provided acceptable results. Thus, this approach can be a viable alternative in the management of adolescent femoral neck fracture with open physis. The femHistorically, different management options for femoral neck fractures in pediatric patients have been of routine use including conservative management with prolonged balanced traction, prolonged casting, percutaneous fixation, closed reduction-internal fixation, and open reduction and fixation with K-wires –14. The We hypothesized that lower bone size, density, and vascular vulnerability could affect the outcome after the fracture fixation and lead to several complications, especially avascular necrosis. Therefore, we thought that a transphyseal fixation combining multiple cannulated screws with 2.5 mm Ø Kirschner wire could increase the strength of the internal fixation, reducing the risk of fixation failure and the incidence of avascular necrosis in adolescent femoral neck fracture. The aim of this study was to present the postoperative outcomes of femoral neck fracture in adolescents with open physis, following transphyseal fixation with combined cannulated cancellous screws and Kirschner wire.22.1.We retrospectively studied all adolescent individuals aged 12–19 years admitted at the first-level trauma center of our institution with femoral neck fracture from January 2011 to January 2021. First, we selected 43 patients with femoral neck fracture (based on plain radiographs and 3D CT scan images), classified according to the Delbet system as transepiphyseal (type I), transcervical (type II), cervicotrochanteric (type III), and intertrochanteric (type IV).The inclusion criteria were: individuals of adolescent age 12–19 years) , 19, pat years , Overall, 19 out of 43 patients met the inclusion criteria and were enrolled in this study. Patients’ data, including postoperative outcome, were collected from medical records, especially the information recorded during the outpatient clinic follow-up visit and the imaging assessment done with standard x-Ray films; those with complains of pain around the affected hip were recommended an MRI to exclude AVN. Data were collected following the anonymous method, and personal identity was completely erased in the data collecting form for ethical consideration. Informed consent was obtained from the parents of all the patients included in this study by phone call using the number found in the medical record, and the study was approved by the institutional review board and the ethics committee of our institution.2.2.The Delbet classification was used to evaluate the risk of complication and was categorized following the definition available in the literature as Delbet type I , type II , type III (cervicotrochanteric), and type IV (intertrochanteric) , 10, 20.Patients who were included in this study were classified as Delbet types II–IV and were managed operatively. The cross-epiphyseal  CCS combined with Kirschner wire was the standard approach technique.2.3.Under the traction frame, femoral neck fractures were reduced using a combination of mechanisms as follows: traction-adduction and internal rotation. When the reduction was satisfied in the anteroposterior and lateral fluoroscopic views, the patient's skin preparation was done with a strict aseptic protocol. An incision of about 3–5 cm in length was made on the lateral side of the hip. The stepwise dissection was done starting from the skin, subcutaneous fascia, deep fascia, vastus lateralis muscle, and the periosteum. The pins guide wire (Kirschner wire) was positioned under fluoroscopic guidance within the femoral neck through the head. The three guide pins were placed in an inverted triangular design with the apex oriented downward. After confirming the correct positions of the three guide wires under fluoroscopy, the lateral cortex was drilled, and three cannulated screws were inserted. The femoral neck was completely reduced and the reduction was satisfactory on the fluoroscopic radiographs. The Kirschner wires were left within the cannulated screws (across the epiphysis) to strengthen the internal fixation . The out2.4.To all patients, a routine outpatient clinic follow-up was recommended weekly for the first month, twice the following month, and then once every 3 months afterward until removal of the internal fixation. The postoperative regular radiographs  were done on every outpatient visit to evaluate the clinical outcome such as fracture healing and potential complications . The postoperative management guideline consisted of non-weight-bearing period of 4 weeks followed by partial weight-bearing for an additional 6 weeks.After complete healing was noticed on the radiograph, we proceeded with partial removal of the internal fixation (the three supportive Kirschner wires with two CCS) usually around 6 months after the operation depending on the clinical appreciation on the radiographs. Complete removal was done after the following three months. This sequential removal allows a complete consolidation and full healing of the fractured neck before complete nail removal is done.2.5.We analyzed, assessed, and recorded all clinical data and outcomes of the patients considered in this study from medical record. We recorded in the data collecting form all the demographic variables of the patients and postoperative follow-up variables such as (1) follow-up period, (2) fracture healing time, (3) nonunion rate, (4) coxa varus rate, (5) osteoarthritis rate, 6) femoral neck avascular necrosis rate, (7) aseptic screw loosening rate, (8) femoral neck shortening rate, and (9) clinical assessment using the Ratliff scoring system  at the last follow-up  (6). The femoral 2.6.Descriptive statistics were used for continuous variables, and the results of statistical analysis were presented as mean and standard deviation (SD); the total number (n) and percentage (%) were used to express discrete variables. All variables were analyzed with SPSS 20.0 .3.A total of 19 patients aged between 12 and 19 years, all operated with transphyseal fixation using combined cannulated cancellous screw and Kirschner wire, were included and retrospectively studied; the results are presented as follows:There was a male predominance in this cohort (76% cases); the mean age was 15.37 ± 2.23 years; the most frequent mechanism of injury was fall after sport activities in school (the height jump), followed by road traffic accident: 66% and 34%, respectively. The right side was frequently injured (57% of cases) and Delbet type III was the most encountered (54%). The mean intraoperative time was 54.71 ± 7.85 min, length of hospital stay (LOS) was 8.34 ± 1.81 days, and time to surgery was 2.60 ± 1.16 days .Radiographic healing was observed after 3.31 ± 1.04 months; coxa vara was encountered in 2 (11%) cases, osteoarthritis in 1 (5%) case, and spontaneous dislocation in 1 (5%) case. The mean ROM was clinically acceptable. Nonunion, femoral neck AVN, and aseptic screw loosening were not encountered in any case of the studied patients. The assessment of femoral neck shortening revealed a moderate shortening in 16% of cases and no case of severe shortening. Clinical assessment with the Ratliff system showed a good result in 89% of patients and a fair result in 11% of patients .4.The treatment approach of femoral neck fracture in pediatric patients is controversial; the current available literature recommend various guidelines such as conservative management with prolong balanced traction, prolong casting, non-weight-bearing period with the use of crutches, percutaneous fixation, and internal fixation using cannulated screw, fixation with K-wires, or Moore's pins , 20–24. Some young patients with femoral neck fractures are close to adults in height and weight, and in the case of patent epiphysis, we chose cannulated screw fixation without crossing the epiphysis; additionally, it is necessary to increase the stability of the implant by inserting Kirschner wires into its inner holes, while reducing the impact of implants on the epiphysis; moreover, for fracture of femoral neck in adults, the standard treatment option is a 7.3-mm diameter cannulated screw. The best choice is a real 2.5 mm Kirschner wire, which is just enough to pass through the hollow screw bore. So we believed that we could use the Kirschner wire in conjunction with our hollow screw to provide the best and strongest biomechanical fixation. In contrast, patients with closed femoral physis are considered to have sufficient bone maturity and the protocol of adult femoral neck fracture management principle is applied; we can safely advance screws further within the femoral neck without the need of Kirschner wires.The choice of internal fixation through the epiphysis, whether it is a cannulated screw or a dynamic hip screw, can theoretically provide better biomechanical stability, but whether it affects the development of the proximal femoral epiphysis or not is inconclusive. Results of trials and long-term follow-up may provide evidence for better treatment options.Fracture classification is an important tool for the management of fracture in any population group. In pediatric patients, Patterson et al.  reportedAVN is one of the most serious complications of femoral neck fracture in children; it is a result of damage to the blood supply of the femoral head caused by fracture displacement during the time of initial trauma and tamponade effect of the hip joint. A rise in intracapsular pressure brought on by hemarthrosis (posttraumatic hemarthrosis) due to the tamponade effect has been associated with avascular necrosis after femoral neck fractures. Intramedullary and synovial venous drainage are disrupted by a femoral neck fracture, which also interferes with intracapsular fluid drainage and increases intracapsular hypertension. The most recent research supports surgical intraoperative drainage of intracapsular hematoma. Evacuation of the intracapsular hematoma has been recommended, especially in nondisplaced fractures, since it may lessen intracapsular pressure and enhance blood flow to the femoral head –27. AccoThe incidence of AVN is closely related to the type of fracture according to the Delbet classification and time to surgery . ControvOn the other hand, some authors associated a higher incidence of AVN to the patient's age, given that this incidence is higher in patients aged above 12 years , 13. RilThe timing of the operation should also be taken into consideration when discussing the predisposing factor for avascular necrosis. Unfortunately, most doctors do not place enough emphasis on pediatric femoral neck fractures. Furthermore, the history of presenting the complaint revealed that, in most patients in our series, patients’ parents or relatives usually reported pain around the hip as “simple muscle sprain, and often think the pain can resolve after few hours”; in fact, people frequently admit that it is the endurance of discomfort beyond more than 24 h that drives them to seek medical attention. As a result, patients frequently arrive late at the hospital; this delay in arrival at the hospital was previously noted by other authors in the literature . These aThe presence of arthritis concomitant with AVN had already been reported; After a long-term follow-up period on 38 patients who received treatment with internal fixation following femoral neck fracture, arthritic changes were found in 18 (34%) patients; the authors reported that there was a strong correlation between the occurrence of avascular necrosis and arthritic change . In the The time to operation probably influenced the incidence of occurrence of complication, notably the AVN. Dendane et al.  reportedIn the current study, all our patients were operated as early as possible (2.60 ± 1.16 days). We did not have any case of AVN, but a direct connection between the times to the operation and the absence of femoral head AVN was not clearly understood. However, we still believed that the quality and stability of the internal fixation played an important role.According to some authors, Delbet type I, II, and III intracapsular fractures are exposed to synovial fluid, which interferes with the fracture healing . In our The neck–shaft angular deformity has also been previously commented. Wang et al.  reportedFemoral neck shortening is also a common finding in patients with femoral neck fracture. Dendane et al.  reportedThe fixation failures including screw loosening and screw breakage are also reported. In a study conducted by Sun et al. , there wOther complications such as nonunion, neck collapse, and delayed union are also common in fracture of the femoral neck. Yeranosian et al.  reportedWe did not register any case of neck collapse among the patients enrolled in our dataset; however, we reported a case of spontaneous dislocation in a noncompliant patient, a 15-year-old male  10 months postoperatively . This diThis study presents some limitations: first, its retrospective nature makes it susceptible to possible minor errors eventually because the patients were selected and not randomly assigned. Second is the lack of consistent available studies using the same treatment protocol with which we could confront our findings; the presence of some confounding variables such as patients’ age, BMI, and fracture type are potentially susceptible to affect the clinical outcome and findings. Finally, this series had a limited sample size and we are aware that this small sample size probably influenced our outcome. Due to the rarity of such a fracture (1%), we could not collect an important number of patients despite the number of years on which we extended our study and data collection.We, therefore, acknowledge that more comparative studies and a randomized control trial are needed to further authenticate our findings.5.In conclusion, in our series, the use of cross-epiphyseal fixation using the combined cannulated cancellous screw with Kirschner wire approach in adolescent femoral neck fractures demonstrated viable outcomes. We, therefore, present this as an alternative for the management of adolescent femoral neck fractures with patent physis.


Brazil represents one of the primary sources of food on the planet and is also the world's largest tropical rainforest, one of the hot spots of biodiversity in the world. In this work, a meta-analysis was conducted to compare several CO2 Brazilian experiments displaying the diversity of plant responses according to life habits, such as trees (79% natives and 21% cultivated) and herbs (33% natives and 67% cultivated). We found that trees and herbs display different responses. The young trees tend to allocate carbon from increased photosynthetic rates and lower respiration in the dark—to organ development, increasing leaves, roots, and stem biomasses. In addition, more starch is accumulated in the young trees, denoting a fine control of carbon metabolism through carbohydrate storage. Herbs increased drastically in water use efficiency, controlled by stomatal conductance, with more soluble sugars, probably with a transient accumulation of carbon primarily stored in seeds as a response to elevated CO2.The CO The Intergovernmental Panel on Climate Change (IPCC) stated that by 2100, CO2 levels might reach the 1300 ppm mark2 and consequently increase the global temperature, needing mitigation alternatives to restrain climate change. The IPCC's 2021 report provides valuable insights into the potential impacts of elevated CO2 concentrations on plants, which can significantly improve plant growth and development. It highlights the need for further research to understand better the complex interactions between CO2 and other climate change factors and their effects on plant physiology, growth, and ecosystem functioning5.The carbon dioxide  are the reduction in stomatal conductance, leaf dark respiration rate, transpiration rate, maximum Rubisco enzyme carboxylation rate, and maximum transport of electrons rate that results in carbon assimilation increase18. The increase in CO2 concentration can stimulate photosynthesis in plants; consequently, the stimulation is influenced by various processes such as carboxylation and product synthesis19. The rate of photosynthesis can be controlled by Rubisco, which is sensitive to CO2, and other less sensitive components19. In maize leaves, eCO2 concentration decreased whole-leaf chlorophyll and protein content20. The stomatal index was also significantly increased in plants grown at high CO2 concentrations20. Furthermore, eCO2 reduced transpiration and water consumption in tomato plants, increasing water use efficiency21 and decreasing leaf transpiration rates22. The increase in leaf dark respiration can result from the direct instantaneous effect of increased CO2 concentration and the longer-term indirect effect due to changes in leaf composition23. The increased carbon assimilation resulting from elevated CO2 concentrations has enhanced different crop species' growth, productivity, and biochemical constituents24. In leguminous plants, eCO2 concentrations have increased chlorophyll, total starch, sucrose, and total carbohydrate content25.The photosynthesis parameters affected when plants grow under elevated CO2 can lead to various biochemical changes in plants, including photosynthesis, respiration, chlorophyll content, and starch accumulation26. Yelle et al.27 investigated the acclimation of tomato plants to eCO2, which observed an accumulation of starch in the chloroplasts. This suggests that starch alone can not fully explain the loss of photosynthetic efficiency in eCO2-grown plants. To understand the biological adaptations to abiotic stress, such as eCO2, it is important to select crops to verify their impact on plant development26.Exposure to eCO2 experiments displaying the diversity of plant responses according to life habits such as trees and herbs28. Performing meta-analyses with data on leaf photosynthesis of forest trees and crops is important because such data are essential for modeling the future of carbon storage and sequestration on the planet30 and also the future changes in agriculture and food production32.Several publications have widely identified changes in these parameters so that large amounts of data can be compiled to provide panels for understanding the climate change effect on plants. One way to analyze and summarize the data is meta-analysis, which affords a comparative analysis of several eCO35, lacking data from tropical (cultivated/exotic or native) plants38 and preventing more accurate analysis of some key regions containing high biodiversity and food production in the world. Contrasting to the high proportion of publications focusing on temperate species, about 43% of all Earth's tree species occur in South America39, with tropical and subtropical plants allocating 52% of the carbon on Earth's surface to biomass storage35.The available data, including meta-analyses, is overwhelmed with temperate climate species2 included a single study from Brazil with coffee trees35. However, considering that Brazil represents one of the primary sources of food on the planet40 and is also the world's largest area of tropical rainforest35, representing one of the hot spots of biodiversity in the world, it would be essential to include studies performed in the region to obtain a general and accurate view of the effects of CO2 elevation for food production and biodiversity.A recent meta-analysis about productivity and its potential for crop adaptation under eCO2 environments in neotropical regions are of great interest due to their importance for understanding the response of these plants to changes in atmospheric conditions. Levy-Varon et al.41 investigated how symbiotic nitrogen fixation influences the tropical forest carbon sink. They found that planted trees can double carbon accumulation early in succession and increase total carbon in mature forests by approximately 10%. It is important to consider the diversity of functional plant communities in understanding the carbon sequestration potential of neotropical plants at eCO2. Rull and Vegas-Vilarrúbia42 performed simulations involving all known vascular flora of the neotropical Guayana Highlands and predicted the potential extinction of approximately 80% of species due to global warming by the end of this century. Despite these studies, there is still a gap in knowledge about the response of neotropical plants to elevated CO2. Studies about the effects of eCO2 on Brazilian plants have been carried out in the last couple of decades46, and it has been recently pointed out that such data remain a gap in meta-analysis works42.Plants in elevated CO2 responses in plant physiological parameters in Brazilian climates, representing a relevant portion of the neotropics. In these analyses, it was possible to: (I) estimate the size of the average effects of high atmospheric CO2 on biomass, biochemical, and photosynthesis parameters and (II) verify whether the eCO2 effects are influenced by the species' life habits (trees and herbs) with the hypothesis that trees and herbs would respond differently to elevated CO2 concentrations.This work aimed to perform a meta-analysis on the eCO2 increased plants' assimilation rate by 44% , transpiration foliar (E), water use efficiency(WUE), and maximum rate of electron transport (Jmax) , stems (245%), and roots (250%)  in herbs increased WUE (117%) . Furthermore, Ci/Ca, Jmax, Vcmax, Fv/Fm, and total Chl in trees and herbs under eCO2 did not change under eCO2  Table . The bion leaves 94%, stemn leaves 94%, stem. 2 Fig. ; Table 1. 2 Fig. ; Table 1 analysis in the analytical models was used to evaluate the variation in results among observations. The high heterogeneity indicates variation in the effect of eCO2 among observations. The heterogeneity was high (I2 > 75) for total biomass, A, gs, Rd, E, WUE, Ci/Ca, Jmax, total chl, starch, and proteins  under eCO2  and assimilation rates control the intercellular/ambient CO2 ratio, which dictates the internal carbon allocation in plants49. Elevated CO2 increases the concentration of intracellular CO2 in leaves38, but to continue the assimilation, the mesophyll CO2 needs to display lower concentrations than the atmospheric partial pressure of CO250. This regulation is performed by the closure and opening of the stomata, which leads to a decrease in stomatal conductance51.Stomatal conductance   represents the primary non-structural carbohydrate in plant leaves under eCO2  that are not readily available to participate in plant metabolic processes60 but can be used to increase biomass in leaves, stems, and roots, as observed in this meta-analysis , suggesting that the predictions made by models of climate change would answer similarly to temperate and neotropical species52. However, in Brazil, relatively few experiments were carried out with eCO2 in plants from the biomes Pantanal, Caatinga, Cerrado, Amazon, and the Pampas, the latter in a temperate region  led to greater starch storage (61%) and a more significant biomass accumulation in tree organs  and soluble sugars such as sucrose and fructose . Understanding these responses would be crucial to predicting the impacts of increased CO2 levels on different types of plants in the face of eCO2 increases.In contrast, herbs, which display shorter lifespans, prioritize rapid growth and reproduction and tend to allocate resources that would support higher water use efficiency (117%) due to decreased stomatal conductance (− 39%) under conditions of eCO2 alone does not represent the complete response of plants to climate change. Combinations of eCO2 with stresses of temperature and water will be necessary to assess the systemic response of plants to global climate change. Thus, more experiments are needed using these parameters that, together with modeling work, could help understand how the neotropics, with their rather large proportion of world biodiversity, will respond to climate change in this century.Finally, it is essential to note that eCO69. For the elaboration of the systematic review, it is necessary to identify and describe the steps taken to study selection and data extraction. These steps must follow a protocol that can be consulted and reproducible69. The flowchart with steps for data collection is shown in Supplementary Fig. 2 on plants was performed in three databases: Web of Science, Scielo, and Brazilian Digital Library of Theses and Dissertations (https://bdtd.ibict.br)72. For each database, a combination of keywords was used 72. Lattes is a Brazilian platform for integrating Curriculum, Research Groups, and Institution databases into a single information system72. The search resulted in a total of 2127 analyzed works in the systematic review  and the control groups (ambient CO2 = aCO2); (b) studies on trees or herbs; and (c) studies with the mean, sample size, and standard deviation of error of the selected variables. The data from articles were grouped as trees and herbs on 28 and 16 species, respectively (Table 2 assimilation (A), stomatal conductance (gs), transpiration foliar (E), water use efficiency (WUE), dark respiration (Rd), intercellular/ambient CO2 ratio (Ci/Ca), the potential quantum efficiency of PSII (Fv/Fm), total chlorophyll content (Chl), maximum carboxylation rate (Vcmax), and maximum rate of electron transport (Jmax)]. The biomass data were collected from total biomass or biomass per plant organ. Each biomass result per organ was considered a biomass observation. Each soluble sugar  was considered an observation for the biochemical category. A dataset contemplated a total of 437 observations. In general, the duration of the studies was 90 days. The average high CO2 concentration was from ~ 400 to ~ 800 ppm. Fifty studies were performed in Open Top Chambers (OTC), 13 in Free Air CO2 Enrichment (FACE), and 7 in Glasshouse (GC). The most frequently studied species among trees was Coffea arabica, with 12 different studies. On the other hand, among herbs was Panicum maximum with six different studies. Fourteen variables were analyzed   74. Data from temporal experiments were considered only the last harvest to represent the maximum exposure of these plants to eCO2 cultivation.Mean values, standard deviation/error, and sample size under eCO2 in growth, biochemical composition, and photosynthesis categories. To evaluate the relative changes of these responses between treatment (eCO2) versus control (aCO2), it was applied the logarithmic response ratio ln (RR), calculated as the size effect, where X̅t is the mean of the experimental/treatment group, and X̅c is the mean of the control group68. The natural log of the response ratio (lnRR = X̅t/X̅c) was used and is reported as the mean percentage change [(lnRR − 1) × 100]75. Values of lnRR higher than zero indicate that the eCO2 effect increases, while negative values indicate that the eCO2 effect decreases concerning aCO2. A hierarchical mixed-effects model was used to estimate the mean and 95% confidence interval (CI) of the lnRR for each type of response variable. If the 95% CI of a response variable overlaps zero, the lnRR of the treatment is not significantly different from the control76. The effect was reported as a percentage change from the control: ((elnRR − 1) × 100). In addition, life habits were used as a fixed predictor variable while the study and species were considered random variables to control for the lack of independence of observations from the same study or/and carried out with the same plant species78. Furthermore, heterogeneity (I2) was tested to verify the variation in results between studies79. The Egger regression test was used to identify publication bias81. Bias analyses for the multilevel models were conducted with meta-analytic residuals77. Analyzes were performed using the package "metafor"82, and the graphics were generated using the package "ggplot2"78, both in R version program 3.6.083.Meta-analysis assessed plant responses to eCOSupplementary Information 1.Supplementary Information 2.Supplementary Information 3.