The Fatty Liver Index (FLI) is a proxy for the steatotic component of non-alcoholic fatty liver disease (NAFLD). For sub-Saharan African populations, the contribution of dietary factors to the development of NAFLD in the etiology of type 2 diabetes mellitus (T2DM) remains to be clarified. We identified sex-specific dietary patterns (DPs) related to the FLI using reduced ranked regression (RRR) and evaluated the associations of these DPs with T2DM. This analysis used data from the RODAM, a multi-center cross-sectional study of Ghanaian populations living in Ghana and Europe. The daily intake frequencies of 30 food groups served as the predictor variables, while the FLI was the response variable. The odds ratios and 95% confidence intervals for T2DM were calculated per one standard deviation increase in the DP score using logistic regression. In males, the DP score explained 9.9% of the variation in their food intake and 16.0% of the variation in the FLI. This DP was characterized by high intakes of poultry, whole-grain cereals, coffee and tea, condiments, and potatoes, and the chance of T2DM was 45% higher per 1 DP score-SD (Model 2). Our results indicate that the intake of modernized foods was associated with proxies of NAFLD, possibly underlying the metabolic pathways to developing T2DM. In sub-Saharan Africa (SSA) and in African migrants living in Europe, type 2 diabetes mellitus (T2DM) constitutes a major health problem ,2, and tTo date, the rapid economic transition and urbanization in SSA as well as the sudden lifestyle changes upon migration from Africa to Europe are among the proposed reasons for the upsurge of T2DM among these populations . The parHere, we present two methodological advancements to study the etiologic pathways from a diet through NAFLD up to T2DM in SSA populations under various transitions. First, the method of reduced rank regression (RRR) is applied to derive dietary patterns (DPs) related to the proxy markers of NAFLD. RRR determines linear combinations of food groups as the predictor variables by maximizing the explained variation in these proxy markers as the response variables . This apConsidering that NAFLD and T2DM frequently co-occur within subjects and share similar risk factors, we hypothesized that RRR-derived DPs related to NAFLD and characterized by modernized foods are associated with T2DM. Therefore, this study aimed to establish sex-specific DPs related to FLI by RRR and determine the associations between these DPs and T2DM among Ghanaian populations under transition.n = 946), urban Ghana (n = 1619), Amsterdam (n = 1900), London (n = 1258) and Berlin (n = 662). For recruitment in Ghana, the census data of 2010 were used to draw urban (Kumasi and Obuasi) and rural participants from the Ashanti Region. The response rates in rural and urban Ghana were 76% and 74%, respectively. In Amsterdam, random selection was performed by using the municipal register to select Ghanaian migrants, who were invited by postal mail and home visits. In Amsterdam, 67% replied by response card or after a home visit, and of these, 53% of the respondents consented to participate in the study. In London, of those individuals who were invited based on their registration in Ghanaian organizations, 75% agreed and participated in the study. Berlin had a participation rate of 68%.The Research on Obesity and Diabetes among African Migrants (RODAM) study is a multi-center cross-sectional study that aims to investigate the relative contributions of lifestyle and other risk factors to obesity and T2DM among African migrants in Europe and their counterparts living in rural and urban Ghana. A detailed description of the study design and procedures has been presented elsewhere . In brieThe study protocol was reviewed and approved by the local ethics committees in Ghana , the Netherlands , the UK  and Germany (Ethics Committee of Charite-Universitatsmedizin Berlin). All participants who took part in the study were thoroughly informed about the purpose and procedures of the study and gave written informed consent.Fasting venous blood samples were collected by trained personnel according to standard operating procedures. Serum and plasma samples were obtained through centrifugation and stored at −80 °C until analysis. The enzymatic method (hexokinase) was used to measure the fasting blood glucose in the plasma. All biochemical analyses were performed using an ABX Pentra 400 chemistry analyzer . T2DM was defined according to the WHO guidelines as fasting plasma glucose ≥7.0 mmol/L or documented use of glucose-lowering medication or self-reported diabetes. The serum lipid profile  was measured using immunoturbidimetric assays. The biomarkers of inflammation and liver function comprised C-reactive protein (CRP), aspartate aminotransferase (AST), alanine aminotransferase (ALT) and γ-glutamyl transferase (GGT). We used two sets of proxy markers to define NAFLD. These were the FLI as a single marker and a selection of biomarkers as the second set of proxy markers. The FLI was calculated for each participant according to the algorithm by Bedogni et al. (2006) . The forA semi-quantitative Ghana-specific food propensity questionnaire (Ghana-FPQ) was used to determine the usual dietary intake of 134 food items. The usual weekly intake frequencies of food groups were documented in pre-defined portion sizes for the past 12 months. We calculated the amounts of food intake (g/d) using common household measures and translated these into energy intake and nutrient consumption by applying the West African Food Composition Table (2012) and the German Nutrient Database 2010). The food items were grouped into 30 food groups according to their culinary use and nutrient profiles [. The foo2).All information on the socio-demographics, education levels, medical histories and lifestyle factors was collected using a structured questionnaire, either self-administered or by an interviewer in the preferred language. The educational status of the participants was categorized into four levels: never or elementary, lower, intermediate and higher or tertiary. Physical activity was assessed using the WHO surveillance questionnaire, and the answers were subsequently classified based on the guidelines of the IPAQ group into three levels of total physical activity: low, moderate and high . SmokingData processing and analysis was performed using the Statistical Analysis Software (SAS) (version 9.4). Participants with missing data for the variables of interest were excluded from the present analysis. Details of the exclusions are presented in Owing to the differences in dietary intakes, adipose tissue distribution, and observed T2DM prevalence between males and females, all subsequent analyses were conducted separately for males and females. First, we used RRR to derive dietary pattern (DP) scores related to the FLI as a proxy marker of NAFLD. The RRR method determined the linear combinations of predictor variables (= 30 food groups) that explained as much variation as possible in the response variable (log transformed FLI). This method has been explained in detail by Hoffmann et al. (2004) . Second,The associations between the RRR-derived DPs and T2DM were calculated by logistic regression analyses. The odds ratios and their 95% confidence intervals (CIs) for T2DM were calculated across the quintiles of the RRR-derived DP scores by using the first quintile as the reference category and per 1 score-SD. To assess the linearity assumption, we calculated the odds ratios and their 95% confidence intervals (Cls) across the quintiles of the RRR-derived DP scores, using the first quintile as the reference category. Linear trends across the quintiles were tested by modeling the median of each quintile as a continuous variable. For the associations with the FLI-related DP scores, we sequentially adjusted for the age (years) and study site  (Model 1) as well as the education level (4 categories), energy intake , smoking status (yes or no), physical activity (METs-h/week), and alcohol consumption (g/day) (Model 2). For the associations with the DPs related to the biomarkers, we additionally adjusted for the BMI and waist circumference (Model 3).In sensitivity analyses, we excluded participants with self-reported T2DM to address a potential source of reverse causation. Specifically, individuals with known T2DM who received medical treatment might have presented altered biomarkers and could have changed their diets. Consequently, we repeated all RRR analyses using the FLI or NAFLD biomarkers as response variables for both males and females. In addition, we repeated the final regression analysis for the association between RRR-derived DPs and T2DM, applying an HbA1c-based definition of the outcome, namely HbA1c ≥ 48 mmol/mol, self-reported diabetes or the use of glucose-lowering medication.2 vs. 27.8 ± 5.7 kg/m2) and waist circumference (87 ± 12.1 cm vs. 91 ± 12.5 cm) were lower in males than in females. The participants in London showed the lowest level of physical activity  and the highest BMI (29.4 ± 4.8 kg/m2) and waist circumference (95.4 ± 11.3cm), while rural Ghana showed the lowest BMI (22.7 ± 4.3 kg/m2) and waist circumference (81.2 ± 10.9 cm) and the highest physical activity level .The estimated mean energy intake was 2533 ± 837 kcal/d, and this was higher among males than females and highest in Berlin, followed by London, rural Ghana, Amsterdam and urban Ghana . The meaIn the sensitivity analysis , similarThe associations with T2DM are shown per quintile and per one SD of the RRR-derived DP scores in In the sensitivity analysis , we applIn addition to the FLI-related DP scores, we also extracted two DP scores related to the biomarkers of NAFLD . The explained variations in the NAFLD biomarkers and the response weights for the RRR-derived DP scores are presented in p for trend across quintiles = 0.0002; OR per 1 score-SD increase: 1.42; 95% CI: 1.20–1.68). However, this association attenuated to the null when adjusting for demographics, socioeconomics, lifestyle and anthropometry. Contrary to the males, there was no clear linear trend for the associations across quintiles with T2DM status (p for trend >0.05). Positive associations ranged from 8% increased odds of T2DM in the crude model (95% CI: 0.93–1.25) to 30% increased odds of T2DM in Model 3 (95% CI: 0.99–1.71) per one score-SD increase.Again, we conducted sensitivity analysis using an HbA1c definition as the outcome variable . The corThe relationships between NAFLD and T2DM with respect to their dietary risk factors informed the derivation of DP scores by applying the RRR method. We used two sets of proxy markers for NAFLD  as response variables and the habitual consumption of 30 food groups as predictor variables. The FLI-related DPs were characterized by frequent intakes of modernized foods and were positively associated with the odds of T2DM. This association was stronger in males than in females. The RRR-derived DP scores using CRP, liver enzymes and blood lipids as the response variables showed inconsistent relationships with food intake between males and females and implausible associations with T2DM.In our first approach, the FLI was used as a proxy marker for NALFD and as the response variable in the RRR analysis. The respective FLI-related DPs were similar between males and females and were characterized by frequent intakes of poultry, whole-grain cereals, coffee and tea, condiments, potatoes, alcoholic beverages, margarine and fish, while fermented maize products, refines cereals, roots, tubers and plantains and palm oil showed inverse correlations with the FLI. These DPs correspond to the nutrition transition observed for SSA populations when experiencing rapid economic growth, accelerated urbanization and migration to Europe ,26.Our findings partly accord with recent evidence from a meta-analysis on dietary risk factors of NAFLD . Red meaWhile many studies confirm the benefits of poultry and fish as part of a healthy diet ,33, thisInterestingly, we observed stronger relationships for the FLI-related DPs among males compared with females, despite the fact that the characteristic food groups and the explained variation in the FLI were similar between sexes. This may reflect the sex-specific contributions of NAFLD to the etiology of T2DM. Indeed, recent findings from the RODAM study confirmed the increased odds of T2DM among participants with an FLI ≥60 compared with an FLI <60. This association is stronger in men  than in women  . FurtherAdditionally, in an urban Ghanaian case control study, Frank et al. derived a DP using RRR that has been positively related with serum triglycerides and inversely related with adiponectin. This pattern is associated with higher odds of T2DM and shares similar features with the RRR-derived DPs in the present analysis, being characterized by high consumption of starchy foods and low intake of fruits and vegetables . The comIn our second approach, we used a selection of proxy markers for NAFLD as response variables for the RRR analysis, comprising liver enzymes, blood lipids and CRP. In this analysis, we observed inconsistent DP scores between men and women and biologically implausible associations with T2DM. Presumably, this selection of biomarkers may not be specific enough to operationalize NAFLD, as they also reflect other metabolic pathways to T2DM, including chronic inflammation (CRP) and dyslipidemia (blood lipids) , which mWhen interpreting the findings of our study, some limitations need to be acknowledged. First, the definition of NAFLD by the use of the FLI as a proxy marker without liver biopsy or imaging may shield detailed information on the severity classification of a fatty liver . HoweverWe identified DPs that showed adherence to modernized foods and a positive relation with the FLI, a proxy marker for fatty liver disease. These DPs were positively associated with the odds of T2DM, particularly in males. These findings give credence to the concept that modernized dietary practices among Ghanaian populations under transition may underly metabolic pathways to NAFLD and T2DM.


Anterior cruciate ligament injury arises when the knee anterior ligament fibers are stretched, partially torn, or completely torn. Operated patients either end up re-injuring their reconstructed anterior cruciate ligament or majority develop early osteoarthritis regardless of the remarkable improvements of surgical techniques and the widely available rehabilitation best practices. New mechanism theories of non-contact anterior cruciate ligament injury and delayed onset muscle soreness could provide a novel perspective how to respond to this clinical challenge.A tri-phasic injury model is proposed for these non-contact injuries. Mechano-energetic microdamage of the proprioceptive sensory nerve terminals is suggested to be the first-phase injury that is followed by a harsher tissue damage in the second phase. The longitudinal dimension is the third phase and that is the equivalent of the repeated bout effect of delayed onset muscle soreness. Current paper puts this longitudinal injury phase into perspective as the phase when the long-term memory consolidation and reconsolidation of this learning related neuronal injury evolves and the phase when the extent of the neuronal regeneration is determined. Reinstating the mitochondrial energy supply and ‘breathing capacity’ of the injured proprioceptive sensory neurons during this period is emphasized, as avoiding fatigue, overuse, overload and re-injury.Extended use, minimum up to a year or even longer, of a current rehabilitation technique, namely moderate intensity low resistance stationary cycling, is recommended preferably at the end of the day. This exercise therapeutic strategy should be a supplementation to the currently used rehabilitation best practices as a knee anti-aging maintenance effort. Anterior cruciate ligament (ACL) injury arises when the knee anterior ligament fibers are stretched, partially torn, or completely torn. The average annual increase of ACL injuries has shown a gradual increase in the past two decades among collegiate athletes , but simNon-contact ACL injury, involving around 80% of ACL injuries , 6–11, iAccordingly, this proprioceptive neuronal impairment is suggested to alter the static encoding of the affected stretch reflex in order to enhance postural control, enhance anti-gravitational capacity and to enhance shock attenuation , 12. SpiIt is notable that very small area, approximately 1%, of ACL consists of proprioceptors and some of them contribute to the position sense of the knee joint –19. AccoWe could possibly learn from the longitudinal dimension of DOMS and that is the repeated bout effect (RBE). Initial bout of severe DOMS-inducing unaccustomed exercise entailing eccentric contractions could be evoked for at least 6 months, but is lost between 9 and 12 months , 30. MorMemory consolidation is a lengthy, time-dependent process leading to altered and strengthened synaptic connections between neurons. The memory dimensions of these proprioceptive TAD like lesions entail several memory pathways, like short-term working memory, long-term episodic memory, inflammation and pain memory . NoteworOverall, we have every ground to suspect that ACL injuries have their own RBE that involves for example the initiation of fear memory consolidation. The lack of extinction of this RBE protective mechanism without the full functional regeneration of these proprioceptive neurons could elongate this ‘third injury phase’ with facilitated long-term memory reconsolidation and accelerated aging. Strategic focus on the maximization of the functional regeneration of these injured peripheral proprioceptive sensory neurons and the minimization of their long-term memory consolidation processes, including fear memory, is what seems to be the missing link.An earlier finding is that long-term or extended, but light to moderate concentric exercise could alleviate the symptoms of the chronic dimension of this type of proprioceptive terminal microdamage or axonal injury , 35. TheImportant to emphasize the significance of these proprioceptive sensory neurons, because they are suggested to be guiding growth, regeneration and remodelling . CurrentModerate evidence is highlighting that the quadriceps torque variability increases over time after ACLR , 38. MorEssential part of the recommended strategy is to avoid further proprioceptive sensory injury, fatigue, overuse and overloading, especially up to at least one year after ACLR, because they could facilitate the compensatory secondary microcircuits with concomitant low-grade neuroinflammation and detrimental facilitation of long-term memory reconsolidation . Good neThe incidence of second ACL injury rates are reported to be 23% , while eImportant to note, that proprioceptive loading has two dimensions after ACLR. First, the secondary spinal compensatory mechanism as a result of the neuronal microinjury and the resultant spinal loading uses more synaptic connections which means enhanced neuro-energetic usage. This secondary compensatory mechanism is theorized to be represented in the delayed latency of the medium latency response (MLR) of the stretch reflex and affects the static encoding of the stretch reflex , 12. AccIndicative from animal studies, that ASIC3 ion channels, in addition to the primary Piezo2 channels, are involved in proprioceptive mechanotransduction , 49. FurMoreover, the two dimensions of proprioceptive loading could be interrelated through GABAergic pathways. The reduction of GABAergic inhibition in the spinal cord ventral horn could contribute to the generation of persistent inward currents and exaggerated quadriceps contractions , 53, as Both of the above proprioceptive loading dimensions are suggested to be alleviated or circumvented by low resistance moderate intensity stationary bicycle training . MoreoveIn addition, the symmetric loading and cyclic feature of cycling have favourable effect on postural control and gait performance  since alAfter all, the take away message is not to stop cycling too early in the rehabilitation process of ACLR, but follow up on an extended way for at least a year or even longer, as a knee anti-aging maintenance effort. It needs to be emphasized that the proposed strategy in perspective cannot hurt and is currently in use in the early stage of ACLR rehabilitation as a best practice solution, but should be prescribed in an extended way!


Background: The coronavirus disease 2019 (COVID-19) pandemic outbreak has posed new problems in the context of patients suffering from other diseases. In particular, musculoskeletal sequelae related to the state of debilitation associated with COVID-19 are important to consider in elderly patients undergoing surgery after lower limbs fracture, especially in the post-operative period. The objective of this study was to evaluate whether COVID-19 influenced biochemical parameter, recovery and mortality of surgically treated patients suffering from lower extremity fractures. Methods: Laboratory and clinical data of 30 patients were extrapolated and analyzed in the pre-operative and post-operative periods. Among these patients, 13 had COVID-19 infection (COVID-19 +), whereas 17 had no signs of COVID-19 infections (COVID-19 −). Long-term clinical and functional outcomes were also analyzed. Results: Lower calcium, slightly higher values of CRP and much higher values of CPK and AST were observed pre-operatively in COVID-19 + patients, who also showed higher prevalence of long-term sequelae than COVID-19 − patients. Conclusions: COVID-19 affects long-term outcome of elderly patients with lower limb fractures in a multifactorial way. First, the virus directly damages the muscle tissue. Secondly, the lung function impairment worsens the overall performance, making rehabilitation more challenging. Fractures of the lower limbs, especially proximal femoral fractures, are quite common in the elderly. This segment of the population is considered particularly fragile due to the numerous comorbidities that can occur with increasing years; hence, it represents a critical group of patients. For these patients, coronavirus disease 2019 (COVID-19) is a further danger. In fact, it was reported that case fatality ratio (CFR) of COVID-19 increases with age. Considering an overall Italian CFR of 7.2%, its values ranged from less than 0.4% in 40 s or younger patients, 1% in 50 s, 3.5% in 60 s, 12.8% in 70 s to 20.2% in 80 s and above [In addition, musculoskeletal sequelae were evidenced in the short term, and they probably persist in the long term after COVID-19 infection . In partIn the musculoskeletal context, falls, which represent the most common mechanism for hip fracture during the pandemic outbreak, can be considered low-energy injuries associated with COVID-19 infection in elderly .The aim of the present study was to evaluate whether COVID-19 influenced post-surgical biochemical parameters, recovery and mortality in patients undergoing surgery after fracture of the femur, tibia or fibula, compared to patients without COVID-19 in the first and second wave of the pandemic in Italy.From April 2020 to November 2020, 30 patients having femur, tibia or fibula fractures were enrolled at IRCCS Istituto Ortopedico Galeazzi. Written informed consent for the participation in this study was obtained from all participants  per lo studio di patologie che interessano l’apparato muscolo-scheletrico e il sistema nervoso centrale”; NCT03208062). The study protocol was approved by the San Raffaele Hospital Ethical Review Board. Demographic and clinical data and serum samples of the enrolled patients were collected.Before surgery, all patients underwent nasopharyngeal swab to determine whether they were infected with SARS-CoV-2 and were hospitalized in a dedicated area, awaiting the result of the molecular test. In case of infection, the patients were transferred to a dedicated ward. All patients were treated surgically, under spinal anesthesia, within 48 h from clinical presentation. They received peri-operative antibiotic and anti-thromboembolic prophylaxis and analgesic therapy. Rehabilitation began, where possible, the day after surgery in order to allow for an early verticalization.As soon as they stabilized from a clinical point of view, the patients were transferred to a facility dedicated to rehabilitation, and they were discharged once they reached ambulatory autonomy. In case of persisting lack of independence, the patients were sent to long-term care facilities or to their home with assistance.Data concerning age, sex, diagnosis, relevant comorbidities, pharmacological treatments, complications and post-surgical transfusion of the patients were collected. The time elapsed between the surgery and the standing positioning of the patient and the mean overall stay in rehabilitation were evaluated. Patients were also evaluated after 8–14 months to assess the long-term outcomes and complications after orthopedic healing. During the follow-up, the most frequently reported complications of COVID-19 infection in the literature were searched in addition to the outcomes closely related to fractures and their management , such asThe clinical analysis was carried out by telephone interview by medical staff experienced in remote assessment. This was executed in order to minimize patient transfers as much as possible, given the pandemic period.Quantitative reverse transcription–polymerase chain reaction (qRT-PCR) of nasopharyngeal swabs were performed to assess the presence of COVID-19. Briefly, viral RNA was extracted using total RNA Purification Kit  and the molecular detection of the SARS-CoV-2 genome was analyzed by RT-PCR using COVID-19 HT Screen kit , targeting N1 and N2 genes. Among the 30 enrolled patients, SARS-CoV-2 genes were detected in 13 patients (COVID-19 +), whereas 17 were negative for COVID-19 infection (COVID-19 −).Routine blood tests were performed on patients’ admission and post-surgical intervention. Hematological analyses  were performed on a Sysmex XN-2000 .Coagulation tests  were analyzed on a Sysmex CS 2500 .® CH Analyzer .Biochemical parameters  were measured on an AtellicaA complete list of the analyzed parameters with their acronym and unit of measure is reported in t test or Mann–Whitney test to compare two groups one-way ANOVA or Kruskal–Wallis tests were used to compare three groups in case of Gaussian or non-Gaussian distribution of the data, respectively. For the analysis of biochemical data, Kolmogorov–Smirnov normality test was used to assess the data distribution. Unpaired p value of ≤0.05 was considered significative, 0.09 ≥ p > 0.05 was considered as a tendency. GraphPad Prism 6.0  was used for the statistical analysis of data. A The evaluation of the presence of long-term sequelae in COVID-19 + and COVID-19 − patients was performed using Chi-square test for dichotomous variables and through the Wilcoxon signed rank test for continuous variables .Thirty patients, all affected by a fracture of the lower limb, were included in the study; in particular, 28 suffered a proximal femoral fracture, 1 a tibial fracture and 1 a hip peri-prosthetic fracture. Among the 30 patients, 13 were COVID-19 + and 17 were COVID-19 −.There were 24 women  and 6 men .The average age of all analyzed patients was 80.6 ± 9.3 years, the average age of COVID-19 + patients was 79.5 ± 8.6 years and that of COVID-19 − patients was 81.4 ± 9.9. Post-operative pharmacological treatments included Low Molecular Weight Heparin (LMWH), antibiotic prophylaxis, nonsteroidal anti-inflammatory drugs (NSAIDS) and steroids administration.At least one post-operative blood transfusion was performed in 66.7% of patients; of those, 61.6% were COVID-19 + and 70.6% were COVID-19 −.In our cohort, 3 patients  were hospitalized in the Intensive Care Unit (ICU) after surgery. All 3 patients were COVID-19 +. One of these patients died from post-operative cardiological complications. None of the COVID-19 − patients required ICU hospitalization after surgery. For overall patients, the mean time elapsed between the surgery and the standing positioning was 3.3 ± 1.3 days; in particular, it was 3.2 ± 1.8 and 3.4 ± 1.3 days for COVID-19 + and COVID-19 − patients, respectively. The mean overall stay in rehabilitation wards was 76.2 days ± 46.4; in particular, it was 75.4 days ± 46.5 and 76, 7 ± 47.7 days for COVID-19 + and COVID-19 − patients, respectively. The time elapsed between hospital admission and the mean follow-up of all patients analyzed was 11.7 ± 2.4 months: 9.9 ± 2.8 months and 13.0 ± 0.4 months for COVID-19 + and COVID-19 − patients, respectively. At follow-up, 36.7% of patients regained a level of independence comparable to that prior to the fracture. This percentage drops to 10% in patients with COVID-19 infection. Return to sociability as before the pathological event was reported in 61.5% of COVID-19 + patients compared to 64.7% of COVID-19 − patients. A higher percentage of COVID-19 + patients (69.2%) complained of sleep disorders compared to 41.2% of COVID-19 − patients. Among COVID-19 + patients, 76.9% complained about a certain degree of mental fog, described as focus trouble or difficulty to remember commonly used names and words. This percentage drops to 17.6% for COVID-19 − patients. Similarly, 76.9% of COVID-19 + and 23.5% of COVID-19 − patients complained of fatigue. Gastrointestinal problems such as loss of appetite, nausea and diarrhea were reported by 61.5% of COVID-19 + patients and 23.5% of COVID-19 − patients. As expected, 46.2% of COVID-19 + patients developed lung problems versus 5.9% of COVID-19 − subjects, following hospitalization for fracture. Moreover, 6.9% of COVID-19 + patients developed dyspnea on moderate exertion, whereas none of the COVID-19 − subjects developed this kind of symptom. After surgery and rehabilitation, 61.5% of COVID-19 + and 35.3% of COVID-19 − patients complained of arthomyalgia. The association between COVID-19 positivity during hospitalization and the presence of long-term sequelae were further investigated. In order to analyze the impact that COVID-19 has on people’s health status and quality of life, the odds ratios of the most frequent clinical manifestations such as mental fog, dyspnea and fatigue in relation to the pathology were calculated and are showed in A total of 38.5% of COVID-19 + patients required the use of a new chronic drug therapy following surgery, compared to 17.6% of COVID-19 − patients. Two COVID-19 − subjects (11.7%) died after surgery and hospitalization. 3/µL versus 0.6 ± 0.2 × 103/µL pre-surgery, p = 0.05). COVID-19 + patients showed a higher number of monocytes pre-surgery in comparison with COVID-19 − patients , without changes during the two first days after surgery.No modifications were observed in the number of white blood cells, in particular neutrophils and lymphocytes, neither from pre-surgery to day 2 post-surgery nor between COVID-19 − and COVID-19 + patients. An increased number of monocytes was noted on day 1 after surgery in COVID-19 − patients , activated partial thromboplastin time (APTT) and fibrinogen. p < 0.0001) and in both COVID-19 −  and COVID-19 +  categories, without differences between groups. Hemoglobin levels significantly decreased from pre-surgery to day 1 and day 2 after surgery in all patients . Lower levels of calcium were observed in COVID-19 + patients pre-surgery (p = 0.02) and day 1 post-surgery  in comparison with COVID-19 – subjects; these values became similar on the second day after surgery. No changes in urea and creatinine levels were observed neither during the first two days after surgery nor between groups. Calcium levels decreased from pre-surgery to day 1 and day 2 post-surgery in all groups  and COVID-19 −  patients, whereas in COVID-19 + patients values increased only from pre-surgery (7.4 ± 6.0 mg/dL) to day 2 post-surgery  since these patients started from higher pre-surgical levels of this protein. No differences in CRP levels were observed between groups. The inflammatory marker C-reactive protein (CRP) increased from pre-surgery to day 1 and day 2 post surgery in all . For these markers, COVID-19 + patients showed higher pre-surgical levels which remained high post-surgery (Muscular markers creatine phosphokinase (CPK) and aspartate aminotransferase (AST) showed post-surgical increase in COVID-19 − group (112.5 ± 124.4 U/L pre-surgery, 272.6 ± 173.7 U/L day 1 post-surgery, -surgery . The data of the present study revealed that the long-term orthopedic complications in patients suffering simultaneously from a fragility fracture of the lower limb and COVID-19 infection are, in general, comparable to fractured subjects that did not experience this viral infection during hospitalization. From a laboratory point of view, our data show that the level of CRP is increased in the pre-operative period in COVID-19 + patients. This is compatible with a viral infection pre-existing at the fracture of the lower limb. The lower levels of calcium observed in COVID-19 + are in agreement with literature reports showing that calcium balance is a primal hit of COVID-19, closely related with the virus-associated multiple organ injuries, the increase in inflammatory cytokines  and the Of note, muscle damage markers, especially CPK and AST, display higher values in COVID-19 + patients. The important systemic inflammation in COVID-19 patients can impact nearly every organ system, including the musculoskeletal system . One-quaFrom a clinical point of view, the hospitalization length and the rehabilitation program were not significantly modified between the two groups of patients. However, COVID-19 + patients presented significantly more long-term sequelae, such as mental fog, dyspnea and fatigue. Thus, our data confirm previous studies reporting long-term disabling problems after SARS-CoV-2 infection .These concomitant pathlogies can negatively impact the recovery after a fracture in elderly patients, who usually suffer from other comorbidities. Indeed, elderlies are more subjected to complications after a fracture. For example, the traumatic event may cause thrombotic and consequent cardiovascular problems. In addition, the prolonged immobilization and hospitalization frequently lead to the development of pressure sores, pneumonia and urinary tract infections in these fragile patients. In this context, the concomitant SARS-CoV-2 infection may further worsen the clinical outcomes, especially in the long-term. Our data did not show a significant worse outcome in these patients compared to subjects without SARS-CoV-2 infection; however, a larger sample size and a longer follow-up may highlight clinical differences between the two groups. In fact, the main limitation of this study is the insufficient sample size, which could prevent detecting significant difference or bias.In conclusion, lower limb fractures in the elderly population represent life-threatening injuries, and surgery is required to provide effective pain relief, enable early mobilization and reduce morbidity and mortality. Despite the presence of SARS-CoV-2 infection, the multifactorial worsening of the long-term outcome of these patients should be carefully managed. In addition, the myalgias and fatigue consequent to the muscular damage caused by the virus may negatively impact the rehabilitation. Moreover, the COVID-19 related lung damage worsens the respiratory function, affecting the patient’s general performance. In this complex contest, particular attention should be paid to treatment of the long-term COVID-19 sequelae in order to improve the clinical outcomes of these fragile patients.


The ongoing COVID-19 pandemic has underscored the need to optimize care for one of the most affected sectors: older adults in nursing homes and more specifically highly vulnerable populations such as residents with dementia. Research developed in collaboration with stakeholders can optimize impact, relevance, and trustworthiness of study findings thereby informing advances in care. Yet, evidence on stakeholder driven research for enhancing dementia care is limited. This symposium will provide examples of stakeholder-driven research questions that were addressed with stakeholder engagement. First, we will present current evidence about the perspectives of caregivers, including those from communities of color. The second presentation will discuss the perspective of clinical training stakeholders responsible for supporting system-wide clinical program implementation and their experiences with early and later adopter nursing homes within the context of a clinical trial. The third presentation will address the perspective of policy makers and payers via the effect of state-mandated dementia training on resident outcomes. The fourth and final present the findings from a study that examined how nursing home stakeholders responded to a payor requirements for pharmacy services and the relationship between that response and patient outcomes. We will conclude the session with a discussion of stakeholder-engagement methods and recommendations for future nursing home research, which champions stakeholder collaboration.


Congenital factor VII (FVII) deficiency is a rare inherited autosomal recessive disorder characterized by prolongation of prothrombin time and low FVII coagulation activity, which may increase the risk of bleeding.A 66‐year‐old man with acute postoperative intracranial hemorrhage was transferred to our hospital owing to coagulation dysfunction. In coagulation tests, the FVII coagulation activity was less than 2%. Genetic analysis of the gene encoding FVII identified compound heterozygous mutations: c. 681+1 G>T and c. C1286T .To our knowledge, this is the first report describing the c. C1286T  mutation in the FVII‐encoding gene. We suggest that these mutations resulted in the reduced FVII activity and abnormal clotting in our patient after brain surgery. Computed tomography (CT) scan showed postoperative rebleeding at the right basal ganglia. The percentage of FVII coagulation activity (FVII:C) determines whether FVII deficiency is mild (>20% but <70%), moderate (10–20%), or severe (<10%).2A 66‐year‐old man with acute postoperative intracranial hemorrhage was referred to our hospital owing to coagulation dysfunction. His Glasgow Coma Scale score was E1VTM2. Laboratory examination revealed a significantly isolated prolonged prothrombin time (PT) (33.6 s) and low FVII coagulation activity (1.8%); the activated partial thromboplastin time and thrombin time were normal. The patient did not take anticoagulants or antiplatelet drugs and had no history of bleeding diseases. We collected and collated the relevant examination reports of this patient, and the results are shown in Figure 9/L; mean platelet volume, 10.10 fL; and platelet count ×mean platelet volume, 0.19). Finally, the activities of other plasma coagulation factors were normal or above normal  but the activities of coagulation factor VII were low (1.8%). Therefore, by process of elimination, our diagnosis was FVII deficiency.Because FVII deficiency is rare, we initially considered the following as potential causes of our patient's coagulation disorder. First, most clotting factors (except for factor III) are synthesized in the liver, and our patient had a history of hepatitis B. However, examination of transaminase levels indicated normal liver function . Second, activation of the clotting factors  is vitamin K‐dependent. Our patient had received vitamin K supplements at another hospital and thus was not vitamin K‐deficient. Third, although platelets are required for coagulation, routine blood tests revealed no abnormalities in platelet number or size  in exon 9.To determine whether our patient's FVII deficiency was acquired or congenital, we used samples of his peripheral blood for second‐generation sequencing: 86 genes related to thrombosis and hemostasis  for 11 days after admission, resulting in a relatively good PT (19.8–24.4 s). He also twice received fresh frozen plasma in combination with rFVIIa, and on the 19th day of admission, rFVIIa alone. The total dose of rFVIIa was 15 mg; for economic reasons, rFVIIa was only administered three times. The PT was maintained at 22.3–24.8 s during the combined treatment. After 2 months of therapy, he was discharged uneventfully.3rFVIIa is considered the most effective treatment for congenital FVII deficiency with severe bleeding, but has three main disadvantages: (1) it requires frequent bolus injections to offset its short half‐life, (2) it is difficult to obtain, and (3) it is extremely expensive. Fresh frozen plasma also has a short life and requires frequent injections; however, it is cheap and easily available and can be used in large quantities over time to maintain a reasonable PT value.F7 mutations uncovered new missense mutations in only 33 of 140 cases of congenital FVII deficiency; among the 140 cases, more than 70 were reported in the past 10 years. Relevant information is summarized in Table A literature search of F7 gene, which is located on chromosome 13.https://f7‐db.eahad.org/). In these cases, the most severe and common symptom was intracranial hemorrhage (2 cases), which was consistent with the patient we reported, and other manifestations included gastrointestinal bleeding (1 case), easy bruising (1 case), menorrhagia, and gum bleeding (1 case). Furthermore, the patients’ age in previous reports was almost less than 40 (3 days–38 years). However, we report a 66‐year‐old congenital FVII deficiency elder patient. Although Ala429 mutations have been reported before ,According to the report, more than 200 mutations, mostly missense mutations, have been identified in the We performed a structural prediction analysis of the FVII protein in our patient. The results showed that the variant Val429 residue was within a hydrophobic region, as is the native residue, and was buried in the serine protease domain (surface accessibility is 1) (Figure During the coagulation cascade, FVII needs to be activated before binding to an exposed tissue factor, thereby initiating the extrinsic coagulation pathway. Activation of FVII requires the participation of the serine protease domain and proteolytic enzymes.4F7 mutation, thus adding to the collection of variant human F7 genes. The specific pathogenesis associated with this mutation requires further experimental investigation.We identified a novel There are no conflicts of interest.Hua Tang contributed to conceptualization, software, and writing—original draft. Xingzhao Luan contributed to software and image curation. Jiaqi Li contributed to methodology and software. Gen Jiang contributed to data collection. Haowen Zhen and Hao Li contributed to supervision. Wei Xiang contributed to conceptualization, methodology, and revision. Jie Zhou contributed to supervision and writing—review and editing.Written informed consent was obtained from the family members of the patient.Supplementary MaterialClick here for additional data file.


We added a layer of BaTiO3 onto the TiO2 electron transport layer and prepared a PSC, which had an FTO/TiO2/BaTiO3/FAPbI3/spiro-OMeTAD/Au architecture with a power conversion efficiency (PCE) of 11%. Further, we used the simulation program SCAPS-1D to investigate and optimize the device parameters  resulting in devices with PCEs reaching up to 15%, and even up to 20% if we assume an ideal structure with no interlayer defects. Our experimental findings and simulations in this paper highlight the promising interplay of multilayer TiO2/BaTiO3 ETLs for potential future applications in PSCs.Since the addition of BaTiO The stock solution molar concentrations of LiTFSI and FK209 were 1.8 mmol/mL and 0.25 mmol/mL in acetonitrile , respectively. Before spin-coating the spiro-OMeTAD layer, the spin-coater was dried with a continuous flow of nitrogen in order to remove residual DMF and DMSO vapors left from the preparation of perovskite thin layers. Afterward, 50 µL of the spiro-OMeTAD solution was spin-coated on the perovskite film  for 10 s. The substrates were left resting overnight in dark and dry air. For the final step, 100 nm of gold contacts were deposited on the substrates by thermal evaporation.2 using a reference silicon cell. The area of one cell was 0.09 cm2 and the potential sweep was performed at a scan speed of 20 mV/s in the range between −50 and 1100 mV. For this paper, a total of 12 solar cells were prepared (six cells at a time) and characterized. The successful cells had similar characteristics so one of them was used as the starting point for the modeling and optimization of the photovoltaic system. The J-V measurements were conducted in a nitrogen-filled glove box using a Keithley 2400  source meter and a DLH400D lamp  calibrated to 100 mW/cm3), which allows efficient extraction of electrons and holes, respectively.The layer structure of the prepared PSCs is illustrated in J–V characteristics including open-circuit voltages (Voc), short-circuit currents (Jsc), fill factor (FF), and power conversion efficiency (PCE). For SCAPS simulations, the input parameters are taken from the literature [The simulation was performed by using the solar cell capacitance simulator SCAPS-1D, which is based on solving one-dimensional continuity and Poisson equations . It can terature ,25,26,27J–V) characteristic of the prepared PSC. The results are shown in J–V characteristics. In addition, the comparison between the main solar cell parameters is shown in Using the data from 3 interlayer is added. When the perovskite layer is prepared on BaTiO3-modified TiO2, its crystal size increases leading to higher light absorption and photogeneration of charged pairs [3 onto TiO2 causes more favorable energy alignments of conduction and valence bands . This may induce a crystallization defect of the absorber layer which inhibits the expected efficient charge separation and transport. The interplay of these factors defines the net efficiency of the PSC.There are several phenomena reported that improve the efficiencies of a PSC when a BaTiOed pairs . At the ce bands b which i3 layer into our previous PSC structure [3 layer thickness on the performance of the PSC was studied in order to find its optimal thickness. We simulated the performance in a range of thickness of the BaTiO3 layer from 10 to 500 nm, and the results are presented in Since we added the BaTiOtructure  to improVoc and short circuit current Jsc stay almost constant with an increase in the thickness of the BaTiO3 layer. The addition of the BaTiO3 layer onto TiO2 causes more favorable energy alignments of conduction and valence bands. Once this alignment is fully developed, increasing the thickness of the BaTiO3 layer will not change it, and therefore Voc will stay constant. The charge separation will not be changed and Jsc will also stay constant. Thus, the only parameter that can influence the PCE is the FF. For this reason, the fill factor FF and the efficiency of the solar cell show the same saturation behavior, with the PCE rising from 9.4 to 11%. Since our experimentally prepared PSC device had a BaTiO3 layer with a thickness of 300 nm, and the PCE calculated from the fitting curve was 10.7% , we decided to take this thickness as an optimal value for further simulations. The experimental PSC with a thicker BaTiO3 layer would improve the device performance by only 0.3%, but would almost double the amount of BaTiO3 used in the production of the PSC.The open circuit voltage AN from 1014 cm−3 to 1019 cm−3. The rest of the parameters were kept constant and corresponded to the values indicated in AN are shown in Doping of the absorber layer is another important parameter that can affect the performance of the PSC, and we simulated the performance of PSC in the doping range of Voc, as can be seen in AN concentration can cause an increase in the recombination rate that can negatively affect cell performance. This can be found in the behavior of the other PSC parameters , the vacancies behave as dopants. The synthesis parameters can influence the nature of the thin film, so the crystallization of the active perovskite layer creates lattice strains, which can lead to vacancies or structural defects as is the case for polycrystalline thin films. The number of present vacancies and the defect concentration depends on the ratio of lead (II) iodide and formamidinium iodide in the precursor’s solution, as well as the choice of solvents  or the lAN increases the recombination rate that strongly affects the J-V curves, reducing the performance of the device , saturating the Jsc and PCE values for absorber layer thicknesses higher than 600 nm. Thus, this value is chosen as an optimum for the thickness of the absorber layer. The Voc also shows saturation for the higher values of the absorber thickness, while the FF is decreasing to 53%.Thinner absorber layers result in lower light absorption leading to lower values of photocurrent, and consequently lower values of 2 have been shown to increase the charge recombination inside the active layer [tN), which can impact the Voc of the solar cell.In order to improve the PSC performance, the change in defect density was considered. Polycrystalline films tend to have a larger number of defects in comparison to monocrystalline films, and synthesis techniques such as crystal-oriented growth  can inflve layer . The recR is given by [n and p are the concentrations of the mobile electrons and holes, respectively. These concentrations can be found by solving the continuity and Poisson equations. At positive voltage values, where qV > 3 kT, the term tE represents the energy level of the trap defects, while tN is their concentration. nτ and pτ are the lifetimes of the electrons and the holes, respectively, and are given by the following equations:nσ and pσ are the capture cross-sections of the electrons and holes, respectively, and thv represents the thermal velocity. To study the influence of the defect density of the perovskite active layer on the cell performance, the Shockley–Read–Hall recombination model (SRH) was used. The neutral defects were set at the center of the band gap following the Gaussian distribution with the characteristic energy value of 0.1 eV, centered in the middle of the band gap. In the SRH recombination model, the recombination rate given by ,35: (1)Rl of the carrier is given by the equation:D is the diffusion coefficient defined by the equation: μ is the charge carrier mobility. According to Equation (2), when defect density decreases, the charge carrier lifetimes increase, leading to longer diffusion lengths (Equation (3)) and a lower recombination rate (Equation (1)). These are the main factors influencing the improvement of cell performance. The diffusion length tN was investigated as a parameter in the PSC performance, and the defect density values were changed from 1014 cm−3 to 1018 cm−3. The change in the recombination rate (R) (Equation (1)) is shown in tN lowers the recombination rate and at the same time increases the diffusion length l.The defect density J–V characteristics reveal an improvement with the reduction in tN. The behavior of the PSC parameters with the change of the tN concentration is shown in tN reduces all the parameters, especially Jsc and PCE as soon as the tN crosses a value of 1015 cm−3. The recombination rate increases and reduces the charge concentration, which further decreases the current through the device. The charge separation is reduced too, so the Voc also drops with increasing tN, and the FF shows similar behavior.Therefore, the reduction in defect density in the perovskite material can significantly improve the performance of the PSC, which is consistent with the simulation results shown in 14 cm−3, but it is very difficult to obtain such a low tN in experiments due to the polycrystalline nature of the perovskite films. Because of that, we set the optimized value of defect density at 1·1015 cm−3. As can be seen from tN, gives the following PSC parameters: Voc = 1.00 V, Jsc = 23.32 mAcm−2, FF = 62.87% and PCE = 14.71%. The J–V curve with these optimized parameters is presented in J–V characteristic (Voc = 1.09 V, Jsc = 28.79 mAcm−2, FF = 66.45%, PCE = 20.79%.The best performance was obtained with the lowest defect density of 1·10teristic . Its par3 layer in between the TiO2 ETL and the perovskite absorber layer, we improved the PCE of a FAPbI3-based solar cell from 7% to 11%. According to mentioned references, we consider that this improvement comes from influencing the electric field, which facilitated better charge separation and transport, and from a reduction in recombination processes. After using numerical simulation and optimization processes with SCAPS-1D, the theoretical PCE rises almost up to 15%. In an ideal device, the efficiencies can even reach 20%, verifying that the BaTiO3 layer can drastically improve the PSC performance and can be used in future research as a promising material for optoelectronic devices.By adding a BaTiO


SCAPS-1D simulation software is used to perform an efficiency analysis of perovskite-perovskite CsPbI3/MAPbI3 bilayer solar cell. For efficiency optimization of the perovskite-perovskite bilayer solar cell, we have tried to calibrate seven parameters of the cell. These parameters are (i & ii) selection of the electron and hole transport material  variation in the: defect density of bulk material, doping concentration and the thickness of absorber layers, (vi) variation in work function of front electrode (vii) varying interface defect density. After optimization, the efficiency (η) of bilayer PSC is estimated to be 33.54%. The other PV parameters observed in optimal efficiency condition are open-circuit voltage (VOC) = 1.34V, short-circuit current density (JSC) = 27.45 mA/cm2 and fill factor (FF) = 90.49%. The CsPbI3/MAPbI3 bilayer perovskite solar cell efficiency is roughly double the efficiency of single junction CsPbI3 or MAPbI3 PSC. Our analysis observed that the variation in the doping and defect density of narrow bandgap material profoundly impacts the efficiency of perovskite-perovskite bilayer solar cells compared to the wide bandgap material.With lead-based light harvesters, perovskite solar cells (PSCs) have an efficiency of approximately 25.5%, making them a viable photovoltaic technology. The selection of the absorber materials for PSC in this work are (i) Cesium lead iodide (CsPbI Bilayer solar cell, Efficiency, Photovoltaic performance, Thickness. First-generation solar cells, or crystalline technology, have achieved efficiencies up to 25% . Second-4 cm−1), high mobility (up to 2000 cm2 V−1 s −1), long diffusion lengths (more than 1000nm) and low exciton binding energies of (2–22 meV)charge carriers [3  has been found to have better thermal stability than the organic-inorganic halide perovskites [3) with a bandgap of 1.73 eV, is optimal for photovoltaic applications and at the same time it is also a perfect material for integrating tandem solar cells with lower bandgap solar cells [3-based PSCs have improved their efficiency from 2.9 percent to 19.03 percent, with better stability, revealing that it has a huge potential for fabricating high-efficiency inorganic PSCs [PSC is the whole new phase of photovoltaic because its efficiency increased sharply in a short duration of time i. e, from 3.8% to 25.5% in a decade. The reason for this accelerated progress can be assigned to some peculiar characteristics of perovskite material, such as tunable bandgaps (1.2eV–2.3eV), high absorption coefficients /(FAMASnGeI3) configuration and Madan et. al [0.5Sn0.5I3/Cs2AgBi0.75Sb0.25Br6) configuration.Thus, PSC became a good choice in the field of solar energy, but due to the complex fabrication techniques of PSC, the invention of simulation tools in this field was promoted. Few solar cell simulation software are SCAPS-1D, AMPS-1D, Silvaco-TCAD, ASA. Using these simulation tools, various combinations of organic-inorganic perovskite materials can be tested, and optimal material combinations can be explored. Using SCAPS-1D recently Singh et.al , achieven et. al , achieve3 and MAPbI3 as the two absorber layers. The selection of MAPbI3 material is due to its higher efficiencies reported in the literature because of the favorable bandgap of 1.55eV, high mobility and long diffusion length of charge carriers. At the same time, the CsPbI3 material is chosen because it is thermally stable and CsPbI3 is also a potential partner for tandem devices because its bandgap (1.73eV) [3/MAPbI3, which cannot be accomplished in conventional thin-film perovskite solar cells, we improve the efficiency of PSC from 14 percent to 33 percent. Up to our knowledge this is one of the highest recorded efficiencies for PSC till now. Our results reveal that the use of narrow-bandgap material MAPbI3 has increased the absorption range of solar spectra and the bilayer fabrication of solar cell have better aligned the energy levels, which promotes the carrier extraction, resulting in higher charge carrier generation and transport of carriers in comparison to single -CsPbI3 or MAPbI3 PSC.In this study, we have focused on optimizing the efficiency of perovskite-perovskite bilayer solar cell using SCAPS (a solar cell capacitance simulator) - a 1D simulation tool with CsPbI(1.73eV) . Hereby 2+ ion. The solar cells are laminated using these tapes and 99.9% of Pb2+ ion absorption is reported [The selection of Pb as one of the components in our work despite being toxic is addressed and resolved by Li et al. In their work they have fabricated DMDP  , 4 methareported .2The fabrication of PSC is a complex process; hence, the scientific community primarily relies on simulation tools for material and process optimization. Various simulation tools like wx-AMPS, SCAPS-1D, Silvaco-TCAD, etc., are available online for research and design. Different research groups develop these simulation codes, and generally, their updates are available from time to time. We have selected the SCAPS (a solar cell capacitance simulator)-a 1D simulator for our simulation study developed by the University of Ghent's Department of Electronics and Information Systems (ELIS) . The simPoisson equation:Continuity equation for holes:Continuity equations for electrons:D+ and NA−, respectively; the electron and hole current densities are Jn and Jp, respectively. G(x) is the electron and hole generation rate while the electron and hole recombination rates are Rn(x) and Rp(x), respectively; and n and p are free electrons, and hole concentration, nt and pt are concentrations of trapped electrons and holes, respectively.Here, ε depicts the permittivity; the electrostatic potential is represented by ψ; q is the charge of an electron, the doping concentrations of donor and acceptor ions are N3) for higher efficiency while (ii) caesium lead iodide (CsPbI3) for better stability. The present simulation is performed in three steps.In our simulation study, two different absorber layers are selected, and the selection of the absorber material is based on (i) the methylammonium lead iodide  and Hole Transport Layer (HTL). Its configuration is FTO/TiO2/CsPbI3/MAPbI3/Spiro-OMeTAD/Au which is depicted in 2 is used as Electron Transport Layer (ETL) (iii) CsPbI3 as the first absorber layer (iv) MAPbI3 as second absorber layer (v) Spiro-OMeTAD as Hole Transport Layer (HTL) (vi) Au as a back electrode.The perovskite-perovskite bilayer solar cell with the two absorber layers CsPbIC and NV stand for effective conduction and valence band density, Eg for bandgap, NA and ND for acceptor and donor density, μp & μn for hole & electron mobility, Nt for defect density, εr for relative permittivity, χ for electron affinity.7 cm/s. The front contact of PSC has a 4.4eV work function, whereas the back contact has a 5.1eV work function. For CsPbI3 based solar cells, the interface parameters include a neutral defect type with a characteristic energy of 0.1eV and located at mid-gap. The captured cross-section for both the electron and hole is 1 × 10−15 cm2. In the bilayer PSC, the interface parameters at the junction of two absorber layer  are interface defect density 1× 1010 cm−3, neutral defect type with a characteristic energy of 0.1eV and located at mid-gap. The captured cross-section for both the electron and hole is 1 × 10−19 cm2.The light spectrum of AM 1.5G falls on the front electrode and, after absorption of a shorter wavelength, transmits to the bottom absorber layer for higher energy photon absorption. The simulation is performed at 300K temperature, the electron and hole velocities are taken as 1033 and MAPbI3 were simulated using SCAPS-1D software. The MAPbI3 based solar cell obtained Photovoltaic Conversion Efficiency (PCE) = 14.34% Fill Factor (FF) = 68.54%, short-circuit current density (Jsc) = 20.59 mA/cm2, open-circuit voltage (Voc) = 1.01V as shown in 3 based device produces PCE = 14.25%, FF = 71.98%, Voc = 1.09V, Jsc = 18.06 mA/cm2 as shown in oc of CsPbI3 PSC is higher than the MAPbI3 PSC because of the higher bandgap of the latter, while Jsc of MAPbI3 is higher CsPbI3 because of better absorption of the solar spectrum by MAPbI3 as compared to CsPbI3 PSC.In the present study, initially, single-junction solar cells CsPbI3 and MAPbI3 PSC closely match each other, validating our simulation study [Tables on study , 26.Tabl3 and CsPbI3. The heterojunction mentioned above allows near-infra-red absorption and hence permits broader absorption of the solar spectrum. It also helps in increasing photo-generation of charge carriers and therefore producing higher current density. The obtained PCE from bilayer PSC = 20.39%, FF = 79.21%, JSC = 27.38 mA/cm2, VOC = 0.93V. The optimization of the bilayer PSC is further obtained by varying the material of ETL and HTL. At the same time, we have varied the thickness, Nt, and NA of the absorber layers. Furthermore, variation of electrode work functions for front contacts of the PSC was observed to achieve optimal efficiency.The study was further continued on all perovskite bilayer solar cell. The two absorber layers in all perovskite bilayer solar cell are MAPbI3.12, SnO2 presents comparable efficiency, i.e., 20.65%, 20.39%, 20.64%, respectively. The justification for the highest efficiency of ZnO can be attributed to better alignment of energy band between the conduction band and lowest unoccupied energy level (LUMO) of CsPbI3 and high mobility of charge carriers, as shown in sc, FF, and efficiency compared to other ETL materials. This observation can be attributed to the low bandgap and low mobility of charge carriers in PCBM, and hence PCBM is not suitable for the bilayer PSC device. At the same time, slight misalignment in the energy level between the PCBM and the CsPbI3 deteriorates the performance of PSC. From 3 absorber layer. Therefore, it is evident from our simulation study that the inorganic materials perform better than the organic materials.In a device architecture, electron transport layers must meet certain requirements, including (i) high band-gap to allow effective light-collection, (ii) well-matched alignment of energy-level for efficient electron transfer and preventing holes, and (iii) high value of electron mobility to reduce accumulation of charge-carriers , 34, 35.3.2−3 cm2V−1 s−1). The unstable, expensive  organic HTMs  leads to the incorporation of inorganic HTMs  with high mobility and carbon-based HTMs for stability [3 as an absorber layer. OC, JSC, FF and η of the resulting PSC. From oc = 0.99V, Jsc = 27.07 mA/cm2, and FF = 84.9%) with respect to other HTL materials simulated. This behavior is attributed to better alignment of the energy level of the valence band of the absorber layer and the highest occupied molecular orbital (HOMO) of the CuSCN. After CuSCN, the performance of PSC in decreasing order is Cu2O, CuI, CuSbS2. The performance parameters with minimal suitable HTL (CuSbS2) are PCE = 18.57%, Voc = 0.88V, Jsc = 27.07 mA/cm2, and FF = 77.92%. Among all the HTMs simulated in our study, the CuSCN showed the best performance, followed by CuI. The reason is that the deeper energy level alignment contributes to the higher Voc, and also, the bandgap of CuSCN (3.4eV) is high enough to block the electron transport completely. At the same time, it effectively transports the holes to the back electrode. Also, its high optical transparency in the 300 nm–900 nm wavelength range allows better light absorption in the absorber layer and, therefore, contributes to the higher Jsc. Thus the simulation reveals that inorganic HTMs perform better than the organic HTMs.The HTL must have adequate energy levels to provide the necessary driving force for charge transfer  must be slightly superior to that of the perovskite materials). It should have a high hole transfer efficiency to enhance hole conduction and prevent charge recombination . We observe that there is a slight reduction in Jsc and a slight increment in VOC on changing the thickness. For efficiency of the cell from 3 absorber layer increases. 3 on the quantum efficiency of the PSC. The maximum efficiency is achieved at 100 nm thickness, and therefore the thickness of CsPbI3 is fixed at 100nm in the rest of the studies. There is a negligible rise in efficiency less than (0.05%/10nm) below 100nm, as shown in 3 is fixed at 100nm elsewhere in the study.In 3 was fixed at 100nm while that of MAPbI3 was varied from 100nm to 1000nm. As observed from sc is significantly improved from 20 mA/cm2 to 27 mA/cm2 due to increased light absorption, which induces a higher photo-generation of charge carriers. The Voc reduces from 1.02V to 0.99V with increased thickness because of an increase in reverse saturation current (Jo), increasing carrier recombination. The FF declines from 87 to 84% due to the rise in the series resistance (Rs) of the PSC. 3 on the quantum efficiency of the bilayer PSC. The highest PCE and quantum efficiency is attained at 900nm. Therefore, the MAPbI3 thickness is fixed at 900nm elsewhere in the study. Our study shows that bilayer PSC performance is more dependent on narrow bandgap material thickness than on wide bandgap material thickness. The bandgap of the CsPbI3 absorber layer is 1.73 eV, hence it can absorb wavelengths up-to 650–700nm, whereas MAPbI3 absorber layer bandgap is of the order of 1.55eV hence it is capable of absorbing wavelengths up-to 900nm. Therefore, increase in the thickness of the CsPbI3 absorber layer creates hindrance to higher wavelength photons to reach the MAPbI3 absorber layer which results in the efficiency decrease of the resulting solar cell.Now the thickness of CsPbI3.4t) of absorber layers is tuned to see its effects on perovskite-perovskite bilayer PSC's performance. The SRH model examined the impact of (Nt) in both absorber layers of PSC.The low-temperature and simple processing in perovskite halides result in significant defects at the grain boundary and interface. The presence of these defects reduces crystal quality. Defects cause perovskites to become active and prone to degradation, resulting in non-radiative recombination, impacting device performance and stability . The defσ: capture cross-sectional arean: electron concentrationp: hole concentrationp: electron lifetime.τn: hole lifetime.τSRH which is inversely proportional to lifetime of charge carriers while SRH is directly proportional to the defect density of material. Thus, on increasing defect density the shokeley read hall recombination rate RSRH increases by suppressing the current density and hence reducing the efficiency of solar cell. The above equation represents the maximum and minimum value of life time of charge carriers and defect density. These equations will give rough idea of life time and defect density but in real simulation more advanced algorithms are used for the estimation of these values at each layer on both sides of layer. The Nt of the MAPbI3 was changed between 1 ×1013 cm−3 to 1× 1018 cm−3, while the Nt of the CsPbI3 was kept constant at 1×1014 cm−3. As the Nt of the MAPbI3 absorber layer increases, efficiency falls from 27.13% to 7.13% the JSC drops from 27.45 mA/cm2 to 11.38 mA/cm2 and the VOC drops from 1.11 V to 0.84 V and FF was reduced from 88.88% to 70.09% and as shown in 13 cm−3 to 1× 1015 cm−3 is the optimal range as the variation in Voc, Jsc, FF and η are negligible, but after 1×1015 cm−3, the efficiency falls sharply.t of the CsPbI3 absorber layer is varied, while the Nt of MAPbI3 absorber layer is fixed at 1 ×1013 cm−3. It can be seen from OC and Jsc do not diminish significantly as the Nt of CsPbI3 rises from 1 × 1013 cm −3 to 1× 1018 cm−3, but FF drops from 88.88 to 81.21%, and the PCE drops from 27.19 to 24.50%. It was determined that when the Nt increases, more recombination centers are created, enhancing carrier recombination within the absorber layer while also reducing carrier lifetime, lowering the solar cell's device performance [OC, as evident from Eqs. t is 1× 1013 cm−3 for both absorber layers, the PV characteristics improves to, current density is 27.45 mA/cm2,VOC is 1.01 V FF 88.88%, and efficiency 27.13%. Thus, the analysis reveals that the Nt of the absorber material has a significant impact on device performance. Also, bilayer.Similarly, the Nformance , 40. As t for the MAPbI3 is 1 ×1015 cm−3 and for CsPbI3 it is 2.07×1014 cm−3 is used elsewhere in the study.PSC performance is more dependent on narrow bandgap material defect density than on wide bandgap material density. Various defect passivation techniques are reported in the literature such as incorporating different additives in perovskite absorber layer using different deposition techniques. Annie et.al, reported hybrid chemical vapor deposition technique and zhu et.al, reported addition of ethylamine alcohol for defect passivation , 42. Theo: ideal FF in the absence of any parasitic resistanceFFk: Boltzmann constant.T: Temperatureq: elementary charge.3.5oc, carrier recombination rate, and diffusion length etc. [A) of MAPbI3 is varied from 1014 to 1022 cm−3 keeping the NA of CsPbI3 fixed at 1014 cm−3. A of MAPbI3 absorber layer on Voc, Jsc, FF, and η and J-V curves of PSC. From the Figure, it is observed that, at low acceptor density, i.e., 1× 1013 cm−3 to 1× 1015 cm−3, there is a small amount of variation in Voc, Jsc, FF, and PCE. But as the value of NA increases greater than 1016 cm−3, we observe a sharp increase in Voc, FF, and PCE. The optimal value of PCE = 28.55%, Voc = 1.23V, Jsc = 26.74 mA/cm2 and FF = 86.69% is obtained at NA = 1022 cm−3. The observed rise in Voc can be explained using the following equations:The doping concentration is another critical parameter that directly impacts numerous optoelectronic parameters, i.e. Vgth etc. . As a reA would drop the saturation current Io, which will subsequently decrease the value of Voc.As it can be seen from the above equation that the rise in N3 was varied from 1× 1013 to 1×1018cm−3, keeping acceptor concentration of MAPbI3 fixed at 1× 1022cm−3, and its effect on Voc, Jsc, FF, and η was studied. Figures A, respectively. Under low acceptor density, the J-V curves are nearly identical, as observed in A is more than 1016cm−3, the JSC falls, and the VOC rises. Eqs. oc is improved, and the JSC drops when NA rises, there will be an optimal NA that maximizes device efficiency, when NA is 1×1015 cm−3, as shown in A is 1×1022 cm−3 for MAPbI3 and 1×1015 cm−3 for the CsPbI3 absorber layer, respectively. Therefore, the above results show that in MAPbI3/CsPbI3 perovskite-perovskite bilayer PSC, the narrow bandgap material is more sensitive to the doping concentration than the wide bandgap material. Various techniques for passivating the traps have been investigated in the literature to improve crystallinity and grain size, chemicals such as metal ionic doping , Lewis acid/base adduct, long-chain polymers, ammonium salts etc. [Similarly, the acceptor density of CsPbIlts etc. , 45, 46.3.6oc, Jsc, FF, and η. OC, FF, and PCE started to degrade and reached 1.14 V, 75.37%, and 22.97%, from 1.23V, 86.69%, and 28.58%, respectively, because a high value of work function was creating a barrier for the flow of electrons at the interface of ETL and front contact. The barrier would rise as it was increased, lowering PV performance, as evident from To assure appropriate collection of electrons from FTO (front contact), an ohmic contact should be established. The work function (φ) of the front contact was increased from 4.1eV to 4.7eV to explore its influence on V3.7interface) at the junction of the two-absorber layer is varied between 1017cm−3 to 1010cm−3 keeping other parameters fixed to examine its effect on Voc, Jsc, FF and η. The PCE decreases from 33% to 7.48% while Voc reduces from 1.34V to 1.02V, Jsc decreases from 27.45 mA/cm2 to 12.60 mA/cm2 and FF decreases from 90.41% to 71.94%. It was observed that the PV parameters changed drastically when the values of Ninterface are varied between 1017cm−3 to 1013cm−3 while PV parameters are almost constant between 1013cm−3 to 1010cm−3 as observed from interface increases. There is greater decrease in Jsc than Voc on increase in defect density. This is due to interfacial recombination dominates charge-carrier density as Ninterface increases. The sudden decrease in Jsc from 22 mA/cm2 to 12 mAcm2 on increase in Ninterface is explained by quantum efficiency curve shown in interface) is greater than 1017cm−3. Thus, simulation reveals that interface engineering is necessary to have efficient solar cells. Interface engineering has been shown to be useful in minimizing power loss and recombination at various interfaces of PSCs [Interface recombination also plays a very important role in determining overall performance of the PSCs . In this of PSCs . As a re43 and MAPbI3 PSC were simulated and validated experimentally. The study was further continued for numerical simulation and analysis of perovskite-perovskite bilayer PSC with a MAPbI3/CsPbI3 heterojunction as the absorber layer. Then we have optimised for ETL material and HTL material. Furthermore, thickness, Nt and NA of both of the absorber layers CsPbI3 and MAPbI3 were optimised.In this work, we have tried to optimize the efficiency of perovskite-perovskite bilayer PSC using the SCAPS-1D simulation tool. We have estimated the efficiency using different organic-inorganic materials, and among them, the best material and optimal thickness of the material is studied. The optimal perovskite-perovskite bilayer PSC shows 33.54% efficiency. Initially, single-junction CsPbI3 absorber layer while it is 900nm for the MAPbI3 absorber layer. Moreover, the perovskite-perovskite bilayer PSC shows the best performance at defect density of 1×1013 cm−3 and optimal performance in the range of 1×1013 cm−3 to 1×1015 cm−3 for both of the absorber layers. It was observed that the moderate doping concentration in the wide bandgap absorber layer and high doping concentration in the narrow bandgap absorber layer produce high efficiency.The study shows that ZnO and CuSCN were the best ETL material and HTL material, respectively, because of better alignment of absorber layer valence band with HUMO and LUMO of ZnO and CuSCN, respectively. The proposed perovskite-perovskite bilayer PSC shows the highest efficiency at 100nm thickness for the CsPbI15cm−3 for CsPbI3 and 1×1022cm−3 for the MAPbI3 absorber layer, respectively. The proposed bilayer PSC shows the best PV performance at 4.1eV front electrode work function and optimal performance in the work function range 4.1eV–4.4 eV. Furthermore, PSC is optimized for defects at the interface of the two-absorber layer in the range 1×1017cm−3 to 1×1010cm−3 and the simulation results demonstrate that for optimal performance the interface defect density should be less than 1×1013cm−3. The PCE has increased from 20.39% before optimization to 33.54% after optimization in bilayer PSC, as shown in 3 based PSC or the MAPbI3 based PSC. Thus perovskite-perovskite bilayer PSC gives higher efficiency than the single-junction PSC.The device shows optimized performance at a doping concentration of 1×10Sidra Khatoon: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Wrote the paper.Satish Kumar Yadav: Analyzed and interpreted the data; Wrote the paper.Jyotsna Singh: Contributed reagents, materials, analysis tools or data; Wrote the paper.Rajendra Bahadur Singh: Contributed reagents, materials, analysis tools or data.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Data will be made available on request.The authors declare no conflict of interest.No additional information is available for this paper.


A thorough understanding of the role of the interfaces in the perovskite solar cell, along with the optimization of different parameters, is still required for further improvement in PCE. In this study, lead-free CsSnGeI3 PSC has been quantitatively analyzed using a solar cell capacitance simulator (SCAPS–1D). Five electron transport layers (ETL) were comparatively studied, while keeping other layers fixed. The use of SnO2 as an ETL, which has the best band alignment with the perovskite layer, can increase the power conversion efficiency (PCE) of PSC by up to 30%. The defect density and thickness of the absorber layer has been thoroughly investigated. Results show that the device efficiency is highly governed by the defect density of the absorber layer. All the PSCs with a different ETL exhibit PCE exceeding 20% when the defect density of the absorber layer is in the range of 1014 cm−3–1016 cm−3, and degrade dramatically at higher values. With the optimized structure, the simulation found the highest PCE of CsSnGeI3-based PSCs to be 30.98%, with an open circuit voltage (ocV) of 1.22 V, short-circuit current density (scJ) of 28.18 mA·cm−2, and fill factor (FF) of 89.52%. Our unprecedented results clearly demonstrate that CsSnGeI3-based PSC is an excellent candidate to become the most efficient single-junction solar cell technology soon.A cesium tin–germanium triiodide (CsSnGeI Energy consumption is expected to increase, with the bulk of the demand coming from developing countries. Conventional fuel remains the greatest contributor to electricity generation worldwide. Producing energy from these resources takes a severe toll on our environment. Solar energy is one of the most abundant energy resources on Earth, as it is sustainable and inexhaustible. Solar cells are regarded as clean and sustainable sources of energy ,2. Couplresource ,4. To dao 32.33% . Kaneka ficiency . Howeverficiency .A decade ago, lead halide Perovskite solar cells (PSCs) emerged as a breakthrough photovoltaic (PV) technology. These cells have acquired significant interest in research and industrial communities due to their high-power-conversion efficiency exceeding 25% ,12,13, s25% ,15. The 10 years ,17, owin10 years ,19,20,2110 years ,23,24,253, CH3NH3SnI3 (MASnI3), and HC(NH2)2SnI3 (FASnI3), have been investigated. The latter two perovskites have intrinsically low stability [3 perovskite could be a promising alternative to Pb-based light harvesting materials, due to its improved photoelectric characteristics such as a high absorption coefficient, small exciton binding energy, high carrier mobility, etc., and is currently the strongest candidate [3 recorded the highest 3 that shows superior performance and exceptional air stability over its pure counterparts CsSnI3 and CsGeI3. The CsSnGeI3-based device shows a Tin-based halide perovskites, such as CsSnItability ,27. The andidate ,29,30,31andidate ,33. Amonof 10.1% ,35. Min of 10.1%  proposed3 perovskite solar cell, by analyzing various device parameters using a solar cell capacitance simulator (SCAPS-1D) [J−V curve, and defect density, by just solving three basic semiconductor equations. It is user friendly and may be executed in both dark and light atmospheres [This study aims to suggest possible optimization routes for efficiency improvements of the CsSnGeICAPS-1D) . DiffereCAPS-1D) ,39. Amonospheres ,41,42. Sospheres ,44.2 and SnO2. TiO2 is the most common ETL for the fabrication of PSC [2 has high electron mobility and keeps better band alignment with the CsSnGeI3 absorber layer, which is supportive for electron extraction [2O was used as the hole transport layer (HTL) due to its low cost, and it is widely used in solar energy materials, as a promising inorganic HTL for PSC applications [3 device can have a simulated power conversion efficiency This work focuses on engineering the interface ETL/perovskite absorber layer. Optimizing the interfaces in the PCSs is essential for enhancing the photovoltaic performance. In this study, different materials were investigated as ETL, mainly TiOn of PSC . On the traction ,46. Cuprications . The imp3, as the light harvesting material using SCAPS, which is 1D solar cell simulation software [In this numerical modeling, a comprehensive study has been performed on CsSnGeIsoftware . The sof3/Cu2O/Au, which is represented in 2O is used for every structure, while five different ETLs are alternately used, and their performances are compared. The ETL includes: SnO2, ZnO, IGZO, CdS, and TiO2. The device simulation is carried out in the 2O 3) layer thickness, The 2, the most commonly used ETL in perovskite studies due to its mesoscopic structure. It is observed that the PSC with SnO2 acquired the highest 3 layer shown in 2/CsSnGeI3 interface. In fact, CBO is the energy difference 2 ETL, the electrons in the ETL layer can easily cross the barrier to attain the interface. The cliff formation can improve the accumulation near to ETL/perovskite, which in turn enhances the recombination in this area by back-transfer to the interface of heterojunction.Surprisingly, all ETLs had superior performance over TiOC device ,59. When2 ETL yields the lowest ocV of FF of Under open-circuit conditions, the interfacial recombination mainly occurs through the pathways of back-transfer recombination, where the electrons that have been injected into the FTO electrode, and the free holes in the absorber recombine through the deep level defect at the ETL/absorber interface, which then result in a serious rovskite ., and 2 is finally selected as the optimal ETL material for the proposed lead-free PSC.Finally, it can be concluded that the band alignment plays one of the key roles for having higher 2 ETL and to determine the influence of absorber defect density on cell performance, the defect density of the perovskite layer has been considered. The defect density values simulated in this study range from Although the interface engineering and the control at the ETL/perovskite interface is crucial for achieving a high-efficiency solar cell device, the morphology and quality of the light absorber film have been recently recognized as a major factor for determining PSC performance , given t on lead ,63. As sThe perovskite defect density effect can be explained by the Shockley–Read–Hall (SRH) recombination model ,65. In tAccording to the SRH model, the recombination rate can be expressed by:The lifetime of charge carriers 3 is It can be deduced from Equations (4)–(7) that as the defect density in the perovskite layer increases, the carrier lifetime decreases, while the charge recombination will increase, as confirmed in e formed , resulti3. Due to the large value of mobility, the diffusion length is high, and that is why our simulated PSC shows a high efficiency of It can be observed from Equation (7) that the diffusion coefficient is proportional to the mobility of charge carrier, the electron mobility Voc=K3 was strongly correlated with the trend of It is seen in 2 layer.QE is reached with an absorber thickness of The larger 3-based perovskite solar cell has been thoroughly investigated. A normal n-i-p planar structure of FTO/ETL/CsSnGeI3/Cu2O/Au is numerically simulated and analyzed using SCAPS-1D simulation software. The impact of various ETL on the device performance was studied to get the highest possible efficiency. It has been demonstrated that a PSC with SnO2 ETL has, by far, the best performance, owing to its excellent band alignment with the perovskite layer. Furthermore, the photovoltaic performance of the cell has been optimized by tuning two major factors: CsSnGeI3 defect density and absorber layer thickness. Our study explained the significant effect of these two factors on the electrical parameters of the PSC. The results revealed that the optimal light absorber thickness and the optimal absorber defect density were 3-based perovskite solar cells.In this work, a novel lead-free CsSnGeI


There is scant data on the association of the Pulsed wave-Doppler tissue imaging (PW-DTI)-derived tricuspid lateral annular peak systolic velocity (S’) and poor short-term prognosis of patients with acute decompensated heart failure (ADHF).A total number of 732 participants from the Heb-ADHF registry in China were divided into three groups according to the corresponding status of tricuspid S′. Demographic characteristics, comorbidities, physical examinations, lab tests, and medications were compared among the different groups. Different logistic regression models were utilized to gauge the relationship between S′ and the risk of a composite of short-term all-cause mortality or 30-day heart failure (HF)-related rehospitalization.p for trend = 0.006] in comparison with S′ at >11 cm/s. When S′ was analysed as a continuous variable, per 1 cm/s increase, the OR (95% CI) for a composite outcome was . Area under curve (AUC) of S′ for predicting outcome of ADHF was 0.631 . Significant inverse association was also observed in left ventricular ejection fraction (LVEF) ≥40% subgroup.The number of composite outcome events identified in the study population was 85, with the short-term all-cause death coupled with 30-day HF readmission events reaching 23 and 62, respectively. As per the multivariable adjusted analysis, S′ was inversely related to the risk of a composite outcome [<10 cm/s odds ratios (OR) 2.90, 95% confidence interval (CI):1.33–6.31; 10–11 cm/s OR 2.18, 95% CI: 1.10–4.33; Inspite of the potential confounders, a more impaired tricuspid annular peak systolic velocity is associated with a poorer short-term prognosis of patients with ADHF. This is the first comprehensive evaluation of tricuspid annular systolic velocity among patients with ADHF.Tricuspid annular systolic velocity could be a predictor of poor short-term prognosis in ADHF.Tricuspid annular systolic velocity should be considered in patients with ADHF at admission. Acute decompensated heart failure (ADHF) is characterized by a relatively swift change in the signs or symptoms of heart failure (HF), thus leading to unscheduled therapy or hospitalization ,2. BurgeSeveral investigations have implicated that the right ventricular (RV) dysfunction is linked to poor outcomes across a broad spectrum of disorders, such as myocardial infarction, chronic HF, and pulmonary hypertension (PH) . HoweverIn summary, we performed a retrospective analysis to assess the relevance of S′ in the poor short-term prognosis of ADHF.The Heb-ADHF (Hebei-acute decompensated heart failure) study (ChiCTR-POC-17014020) is a prospective, multicenter, and observational study, which enrolled patients discharged from hospitals with a main diagnosis of HF in accordance with Chinese HF guideline , PH(PASP >40 mmHg), and pulmonary artery (PA) diameter. S′ was used to quantify RV systolic function and was obtained from a RV- focussed apical view as the Doppler beam parallelly aligned with RV free wall longitudinal excursion. Baseline characteristics were compared among the three groups of patients according to S′ tertiles: <10 cm/s , 10–11 cm/s , and >11 cm/s . The group 3 (>11 cm/s) was reckoned as a reference for statistical analysis. S′<10 cm/s was defined as RV systolic dysfunction on the strength of recommendation from American society of echocardiography  in the fully adjusted model. The fully adjusted model was considered well-adjusted in the light of the Hosmer-Lemeshow test  and is depicted in We identified 85 composite outcome events within the 30 days of follow-up on every single discharged participant of the study population. The in-patient all-cause mortality of our present study was 2.3%, which is similar to the upshot observed in a previous study . Meanwhi–0.690, p < 0.01)  was calculated, which was 0.631 (95%CI: 0.573 < 0.01) . In addip for trend = 0.011] in comparison with S′ at >11 cm/s  had a significant higher risk of short-term all-cause mortality or 30-day HF rehospitalization, with more adverse events detected across the escalating impaired S’ severity. This was independent of potential confounders, such as age, sex, comorbidities, physical examinations, lab tests, baseline medications, and echocardiographic parameters. These findings imply that S’ may serve as a useful tool to identify the patients with ADHF that are at a high risk of adverse events, and thus the evaluation of S′ should be reckoned as a part of the comprehensive assessment of this condition.The structure of the right ventricle is characterized by a thin wall and irregular shape, with a high afterload sensitivity. Therefore, the Simpson’s method, which is commonly used to calculate the LVEF and is one of the significant indices for evaluating the LV systolic function, is not applicable to assess the right ventricular ejection fraction (RVEF) in clinical practice. Several previous studies have verified a correlation between RVEF and adverse outcomes in different HF populations using various methods of RVEF assessment, which are not widely used in clinical practice owing to the disadvantages we mentioned above . CurrentTill date, cumulative studies have confirmed that RV dysfunction is a prognostic factor of undesirable outcomes across a string of cardiac conditions. In 1998, De Groote et al. corroborated that RVEF is an independent predictor of survival in patients with moderate CHF. In 2010, Meyer et al. proved that baseline RVEF <20% is a significant independent predicator of mortality and HF hospitalization in systolic HF. In 2014, Melenovsky et al. reported that the right heart dysfunction is common in HF with preserved ejection fraction (HFpEF) and is driven by the RV contractile disability and afterload mismatch from PH. A recent study demonstrated that lower RVEF is associated with incident HF or death and was independent of LVEF among individuals free of HF . HoweverFew investigators reported that PH correlates with the S′ of tricuspid annulus below 12 cm/s. However, this finding has not been verified using right cardiac catheterization. As a complex and often misunderstood disorder, PH mostly results from the left cardiac conditions such as HF with reduced ejection fraction (HFrEF) and HFpEF ,36. Our Our findings also spotted that the systolic dysfunction of right and left ventricle coexist in a large portion of patients with DCM due to its highest prevalence in group 1. Likewise, ORs and 95% CI (S’) are consistent with the results before and after adjusting the DCM.n = 732) afflicted by all types of ADHF (LVEF ranging from 12 to 75%) expands previous awareness by displaying an inverse correlation between S’ and risk of short-term all-cause mortality or 30-day HF readmission. There might be other explanations for the relationship; however, the findings are intriguing enough to warrant further investigations that focus largely on the comprehensive echocardiographic parameters of RV systolic function both in and out of the hospital setting. In this way, we would be capable of discerning high-risk patients with ADHF as well as optimizing preventive interventions to improve the prognosis of people with ADHF.Our present study with its relatively large study population  and tricuspid annular plane systolic excursion (TAPSE). However, we applied few major echocardiographic variables in the multivariable and sensitive analyses, and the results are consistent from start to finish. Lastly, we chose the Chinese participants as the study population, and this may limit the generalizability of our findings to other ethnicities.Inspite of potential confounders, a more impaired tricuspid lateral annular peak systolic velocity is associated with a poorer short-term prognosis of patients with ADHF. Tricuspid annular systolic velocity could be an independent predictor of poor short-term prognosis in ADHF, and thus it should be considered in patients with ADHF at admission.