The current spread of dementia is engendering an emergency that is not limited to the medical issues but also involves its social dimension. Accordingly, it is necessary to promote a perspective change about the disease that supports a more inclusive view of people with dementia. To ensure this, Dementia-Friendly Communities (DFCs) have recently been developed. Nonetheless, it is not always effortless to deal with people with dementia in an inclusive way because of misconceptions about how they perceive everyday contexts and react in everyday situations. We asked 170 individuals (aged between 13 and 75) to “put themselves in the shoes of a person with dementia” for a few minutes, facilitating this through the use of a 360° video, and to try to experience how activities such as going shopping feel from the first-person perspective. Before and after the experience, participants expressed their opinions about the needs and the autonomies that are deemed to be granted to a person with dementia. The results revealed changes to social perspective after having experienced firsthand what living with dementia could be like. A deeper comprehension of what it is like to live with dementia appeared to be gained, and participants’ beliefs about the needs and daily autonomies of those with dementia were modified after the experience. It is possible to conclude that, through the change of perspective, people are more willing to be inclusive toward people with dementia, as is wished for in the DFC approach, although a wider formative intervention on how to be really inclusive still seems to be required. The latest research developments on dementia have shown that there are still no unequivocal data about the causes of this disease . Nor is Consequently, in parallel with research on maximizing the effects of prevention strategies  and to sDespite this effort, the concrete actions that support the community of citizens in becoming Dementia-Friendly clash daily with the misconception of dementia , which f® has been widespread in the United States for many years; this is mainly aimed at caregivers and family members of people with dementia, showing them how some sensory and motor limitations can compromise the ability to solve simple problems The need for continuous assistances after the dementia diagnosis.(b)The possibility of having a large amount of autonomy in daily activities.(c)The exclusive role of professionals in supporting dementia people.2.What the demands of people with dementia are, in terms of those expressed by (a)To have basic needs  granted.(b)To have psychological needs  granted.(c)To have self-actualization needs granted.3.What the possibilities of becoming Dementia-Friendly are through(a)Improved knowledge about dementia.(b)Modification of the perceived difficulty of being a friend to a person with dementia.All participants were volunteers attending a public event in which the VideDe project was presented.M = 39.29, SD = 17.78). Additionally, 99 participants declared that no relative of theirs was diagnosed with any form of dementia, whereas the remaining 71 did have such a relative.In total, 170  took part in the experiment, with ages ranging from 13 to 76 years  took approximately 20 minutes. The experiment timeline is depicted in Data were collected in an anonymous form through the use of an interactive table placed at the entrance of the experimental setting. By clicking on the touch screen, participants provide to the experimenter information about their age and familiarity with dementia (Do they work with dementia? Are they relatives of people with dementia?).Moreover, in order to explore the research hypothesis, on the interactive table participants have to:1.Answer three questions to provide their opinions about the prerogatives of people with dementia. The questions are answered on a five-point Likert scale. The questions are about:(a)Assistance: Do you think that people with dementia need to have continuous familiar assistance during everyday activities?(b)Autonomy: Do you think that people can continue to autonomously meet their personal needs (such as going out to purchase goods or doing their housekeeping) just after a dementia diagnosis?(c)Institutionalization: Do you think people with dementia have to immediately ask for support from institutional welfare  after their first diagnosis?2.Click on a pyramid image that represents the five levels of individual needs defined by 3.Answer two questions to provide their opinion about the perceived difficulty of becoming Dementia Friendly, in particular in terms of taking care of people diagnosed with dementia (“Please indicate on the depicted line a point that corresponds to how demanding you think it is to live with a person with dementia”) and in terms of the knowledge on dementia they believe they have (“Please indicate on the depicted line a point that corresponds to your knowledge on what dementia is”). The questions are answered on a 10-point Likert scale .2) and a set of headphones. Participants immersively experienced a 360° video downloadable on their smartphone from the www.vivede.it website. The video provides a six-minute experience of a person with dementia doing their daily shopping at the neighborhood bakery and greengrocer. In the video, a typical daily situation is represented . A video snapshot is provided in https://youtu.be/A15h8_UHWE4.After the touch-screen phase, participants were conducted to a separate dark room within which they had the ViveDe experience. The experience was made possible through the use of the Homido virtual reality Headset V2 . Moreover, the participants can hear firsthand the voice of a person with dementia as if it is their “thoughts.” The video, like the others developed in the ViveDe project, is the upshot of a previous research phase in which people with dementia, caregivers, and urban communities were involved in providing qualitative and quantitative information about how difficult is it to face everyday challenges when living with dementia (The 360° video is fully explorable on the dementia .The only factor was “Time.” All participants filled the questions before and after the ViveDe experience. The dependent variables were:(a)Prerogatives of people with dementia. Three questions measured on a five-point Likert scale  exploring the perceived need for assistance in dementia patients, the perceived right for autonomy, and the perceived need to be relocated to specialist health and social structures.(b)Demands of people with dementia. The eight clusters reported in (c)Possibility of becoming Dementia-Friendly. The perceived knowledge of the respondent about what dementia is and their perception of the difficulty of living with a person diagnosed with dementia, on a Likert scale ranging from 1 to 10, with no specific label.The hypotheses concerning participants’ opinions about the prerogatives of people with dementia and participants’ opinions about the perceived difficulty of becoming Dementia-Friendly were explored by using SPSS 22 statistical software.To explore participants’ opinions about the individual demands of people with dementia, analyses were conducted using Sleipner 2.1, which is a statistical package used for typological analyses and for studying individual development, that is, stability vs. change . An indiThe five levels of Maslow’s pyramid of needs were grouped into three possible levels: a base level (basic needs) including physiological needs and safety, a second level  including social belonging and esteem, and a third level  focusing on self-actualization only , 1954. IThe analysis was conducted using the EXACON module of Sleipner, which produces a contingency table for two categorical variables, in our case, cluster membership at T1 and T2. The EXACON procedure focuses on cell-wise analysis of types based on exact tests. Specifically, a type is said to occur in a cell if the observed frequency is much larger than the expected frequency and the associated hypergeometric probability is low; that is, we observe a significantly larger frequency than we expect to observe by chance alone. In the opposite case, an antitype is said to occur. In other words, this analysis evaluates the T1-to-T2 sequences of clusters for perceived needs to verify whether these sequences occur differently than expected by chance.F, Wilks’ λ = 14.10, p < 0.001. At a univariate level, the effect for the question concerning assistance was not significant, F = 2.77, p = 0.09, partial η2 = 0.02. On the contrary, the effect was significant for autonomy, F = 34.65, p < 0.001, partial η2 = 0.17, and for institutionalization, F = 11.25, p < 0.01, partial η2 = 0.06. As Before running any analysis, correlations among the three questions were evaluated. As p = 0.02, cluster 4, p < 0.01, cluster 7, p < 0.001, and cluster 8, p < 0.001. Four cells show that more participants than expected re-emerged in a different cluster at T2. This happened, for example, for changes from cluster 2 to cluster 3, p = 0.03, for changes from cluster 3 to cluster 5, p < 0.01, for changes from cluster 5 to cluster 3, p < 0.05, and for changes from cluster 6 to cluster 8, p < 0.05. Four cells show that fewer participants than expected re-emerged in a different cluster at T2. This happened for example for changes from cluster 3 to cluster 8, p < 0.05, for changes from cluster 7 to cluster 8, p < 0.001, for changes from cluster 8 to cluster 3, p = 0.02, and for changes from cluster 8 to cluster 7, p < 0.001.These results illustrate that: (a) the majority of participants tended to recognize that all of the three levels of needs described by Maslow’s pyramid should be granted to people with dementia and (b) there is a general trend to “move up” toward the higher level of needs represented in the pyramid from pre- to post-experience.r = 0.13, n = 170, p = 0.09. The correlation post-experience was significant, r = 0.19, n = 170, p = 0.01. Due to this last correlation, a MANOVA with Time  as the factor and perceived difficulty and perceived knowledge as dependent variables was run. There was a significant multivariate effect, F, Wilks’ λ = 53.88, p < 0.001. At a univariate level, the effect for knowledge was significant, F = 107.64, p < 0.001, partial η2 = 0.39. Participants increased their perceived knowledge from M = 4.71 (SD = 2.08) pre-experience to M = 6.06 (SD = 2.08) post-experience. In contrast, the change in perceived difficulty from pre-experience, M = 7.94 (SD = 1.66) to post-experience, M = 8.04 (SD = 1.64) was not significant, F = 0.60, p = 0.43, partial η2 = 0.00.The correlation between the question about the perceived difficulty of taking care of people diagnosed with dementia and the question about perceived knowledge about dementia was explored. Such a correlation was not significant before the ViveDe experience, The results showed that the ViveDe experience had an impact on how participants considered dementia. Although the idea of needing assistance is not changed by the first-person experience, it significantly reduces the idea that assistance should be delegated to welfare professionals . We could consider this as a greater positive disposition toward the autonomy of a person with dementia, but we see, however, that this was not confirmed by the analysis. The disposition toward autonomy, though it changes significantly, appears to become more negative. This result is apparently not consistent with the assumptions but can be understood in the light of the firsthand experience provided by ViveDe 360° video.Precisely because, in an everyday life situation considered to be simple to manage (like buying bread and fruit in a neighborhood shop), the participants felt like they were not able to complete the task without the collaboration of others (the shop managers and the attending customers), a “stereotyped” idea of autonomy materialized from the experience of “frustration” in autonomy. This was to such an extent as to lead participants to change their opinion toward the conception of autonomy to become more restrictive. Therefore, though, on the one hand, this fact confirms the transformative potential of the immersive experience, it also leads us to expand the educational pathways about conceptions of autonomy and the effort required to give assistance to people with dementia within a really inclusive urban community. Indeed, in a Dementia-Friendly perspective, citizens are informed and trained about inclusive behaviors that can best support the autonomy of the person with dementia by avoiding the spontaneous errors of interaction that the participants probably experienced within the video.This finding appeared to be confirmed by the answers to the knowledge/difficulty questions, in which participants after the experience significantly changed their evaluation of what they knew about dementia but not on the estimated difficulty of being Dementia-Friendly. ViveDe video appears to be successful in being informative about how people with dementia live and how they experience the urban surroundings, but the participants did not receive any new insights into how to supportively interact with and on how to include people with dementia in a daily situation. This suggests the direction in which the interactive dimension of the next ViveDe videos has to be more carefully developed.Finally, one of the clearest unexpected findings was provided by the positioning on Maslow’s needs pyramid both pre- and post-experience. Not only did the majority of the participants “recognize” that people with dementia have the right to have their basic needs  fulfilled – by highlighting the “welfare” nature of the caregiving relationship – but it appears clear that the participants recognized from the beginning that they also have the higher-level needs  that are generally the needs of any person, regardless of illness. Probably, precisely because the sampling of the participants was on a voluntary basis and the ViveDe experience was proposed indiscriminately to a wide audience, the individuals who participated in the experience did so already thinking that people with dementia have a wide range of needs. In addition, after the ViveDe experience, the urge to consider the needs of a person with dementia appeared even stronger in our participants. In fact, they significantly revised their choices by adding the needs at the higher positions in the pyramid, even when they had not done so previously.In conclusion, our participants showed they took part in the research with an already assimilated idea of “being a person with dementia” (as advocated by Kitwood’s perspective) and were predisposed, before the ViveDe experience, to be in some way Dementia-Friendly. Moreover, having the opportunity to understand what it could mean to be in that situation by taking a firsthand perspective on dementia enabled participants to revise some opinions about the challenges and skills that an observer generally tends to attribute to a person with dementia when watching a daily interaction from a third-person perspective. This perspective change definitely produced new familiarity with dementia, but it also raised new questions about what daily practices are more suitable to being faced by a person with dementia. Our participants, in fact, significantly modified their understanding of dementia but not their estimation of the difficulties of becoming inclusive toward people with dementia. It must be borne in mind, however, that one important limitation of this study was the lack of a control group and/or a longitudinal measure; hence, the results must be taken with caution. Concerning the former, it is possible that a control group would not be of much help to understand the change of perspective, as control participants would just answer the same questions twice in a very short time-window. As far as the latter, future research should also explore how the change in perspective is affected after longitudinal and repeated exposure to the experience. Future studies could have different aims: to evaluate whether longer exposures to the experience may reinforce its positive effect, as suggested by post hoc focus on how to convey effective community change that directs toward full inclusion of people with dementia.Furthermore, the findings presented in this study, even if it could be considered as one of the first significant results in this field, still leave open the question of how to strongly convey a social perspective change that really takes us in the direction of the construction of a stable Dementia-Friendly Community. We acknowledge that ours was a temporally circumscribed intervention, but it had a high experiential and transformative potential. Unfortunately, we cannot measure this change through follow-up monitoring of our participants or explore whether their future actions changed toward being more Dementia-Friendly when they returned home. Thus, although it has shown to be effective, the ViveDe experience still needs a Data access is restricted to protect confidential information about a personal point of view on dementia that can be erroneously considered outside the research context. To access the dataset contact the corresponding author. Data will be available on request with the permission of the third party.This study involving human participants was reviewed and approved by University of Bergamo. Written informed consent to participate in this study and for the publication of any potentially identifiable images or data included in this article was provided by the participants.FM ideated the research. FM, PS, and NP conducted the experiment. FM and NP wrote the manuscript. FM, NP, and AG collaborated on data analysis. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Approximately one-third of people with dementia in the United Kingdom live alone. People living alone with dementia may receive different treatment for dementia and may have different comorbidities compared to people who live with a caregiver. This study explored differences in medication and demographic characteristics between people living alone with dementia and those living with a caregiver in Northern Ireland. People with dementia were identified through the first date that a dementia management medication was prescribed between 2010 and 2016. In total, 25,418 people were prescribed a dementia management medication. Data for whether people with dementia lived alone was extracted through the National Health Application and Infrastructure Services and from national datasets through the Honest Broker Service. Approximately 35%  of people with dementia in Northern Ireland lived alone. People with dementia who lived alone were younger  compared to people who lived with a caregiver . Binary logistic regression highlighted that people who lived alone were more likely to be treated with donepezil medication for dementia and less likely to receive antidepressants. These findings indicate that living alone did not affect treatment for dementia and comorbidity medication in people on dementia medication. Approximately one-third of community-dwelling people with dementia in the United Kingdom and the United States live alone; these rates, however, are higher in other countries, such as Germany 51%) and Sweden (46%) % and Swe. In 2010The presence of a caregiver is likely to affect therapeutic decisions as informal primary caregivers can help ensure that the person with dementia receives treatment, help with drug adherence and help with the management of side effects of treatments . ConversOne study exploring differences between people with dementia living alone with those who live with an informal caregiver found no differences in the management of medication-related problems, such as adverse reactions, as well as in nutrition, quality of life, or cognitive and functional impairment . Other sAlthough past research has explored the unmet needs for people with dementia who live alone , includiFrom 25,418 people with dementia , 8,828 people lived alone and 12,200 people lived with another person in January 2010 . The remThe binomial regression model Model 1, , when co2(1)= 153.516, p< 0.001], were less likely to live in rural areas , less likely to be married  and more likely to receive donepezil . In comparison to people living with a non-adult, people living alone with dementia were less likely to receive medication for hypercholesterolemia  and hypertension , as well as less likely to receive anxiolytics , antidepressants  and antipsychotics .Analysis between people living alone and people living with a non-adult  showed that the former group were significantly younger , were more frequently females , married , lived in rural areas , and lived in more deprived areas  compared to people living with another person with dementia. People living alone were less likely to receive memantine , but more likely to receive medication for hypercholesterolemia .Finally, analysis was carried out between people living alone and people living with another person with dementia (n=278). People living alone were younger , more frequently females [65% and 59%, χThis study explored whether people living alone with dementia had differences with respect to their demographic parameters and comorbidity medications in comparison to people with dementia who lived with at least one other person. Almost 35% of people with dementia in Northern Ireland live alone in their own home. This rate is similar to the one-third of people living alone with dementia in the whole United Kingdom and in the United States , but lowSimilar to past research, our results showed that people living alone with dementia were more likely to be female, were less likely to be married and more likely to be widowed , 2, 4. MIn contrast to research evidence from Sweden, Germany and France , 2, 4, 6Furthermore, the younger age of people who lived alone may also explain why they received medication for less comorbidities compared to people who lived with a caregiver. Another possible explanation is that the presence of a caregiver is associated with better treatment adherence and management of any side effects  and thusPeople with dementia who lived alone were more likely to receive Donepezil; this may be because of their younger age and fewer comorbidities hence they may be able to tolerate it better . Past reAlthough the results from this study contribute to important findings about drug treatment in dementia, several limitations should be considered. People with dementia were identified through their dementia medication and thus, our sample potentially included mainly people with Alzheimer’s disease, mixed dementia and Lewy Body dementia. In addition, people who lived alone could receive care from friends and relatives who did not live with them. Research has shown that people who live alone with dementia are often supported by their siblings, children and grandchildren . The EPDTo conclude, the present study showed that people living alone with dementia are equally or even less likely to be prescribed medication for comorbidities compared with people who lived with someone else. This can be explained by the absence of a caregiver as well as by the support provided by health and social care services in Northern Ireland. The present results should be considered by local authorities in health services for future planning. Finally, the public and voluntary sectors should continue to provide vital information for people who live alone with dementia, such as for staying safe and dealing with loneliness and depression .Similar to previous studies, people with dementia  were identified using data which was extracted from the Enhanced Prescribing Database (EPD). The first date that a dementia management medication was prescribed was used as a proxy for a dementia diagnosis , 9. The Dementia and comorbidity medications were extracted through the EPD and are explained in our past research . ComorbiDescriptive information is presented as frequency , means and standard deviation (SD). Comparisons between people who lived alone and people who lived with another person were conducted with chi-square tests for categorical variables, and with independent-samples t-tests for continuous variables. Chi-square and t-tests were also conducted to compare data between people living alone and people living with an adult, a non-adult or another person with dementia. A binary logistic regression model was used to estimate the odds ratios (ORs) and the 95% confidence intervals (CIs) for the relationship between living alone, demographic characteristics and medication use. A significance level of <0.05 was assumed for all statistical analyses. We analysed the data based on complete case analysis to deal with missing data.


BAT is activity . Howeveractivity . We induEQUIPMENT: Albira Si PET/SPECT/CT (Bruker), Xtreme II optical imaging system (Bruker)REAGENTS: XenoLight RediJect 2-DeoxyGlucosone (DG) (PerkinElmer), CL316,243 (Sigma)


This paper reports on the long-term effectiveness of a non-formal co-curricular educational program based on a campus ecogarden at a Hong Kong university in developing pro-sustainability awareness, attitudes and behavior among undergraduate students. This service-based, nature-based experiential learning program, termed the Ecogarden Farmer and Biodiversity Surveyor, has been running at the university since 2015. The program is divided into two consecutive phases: a training phase comprising various learning activities and a successive internship phase consisting of the all-round practical tasks involved in managing the garden. A retrospective evaluation of the program using phenomenographic approach and content analysis was adopted to reveal the diversity of students’ learning experience, as the indicators of the success of the program. Of 112 participants from 4 cohorts, 32 completed online questionnaires, and semi-structured interviews were successfully conducted with twelve participants, three from each of the four cohorts. The results indicated that the program’s outcomes could be categorized into five themes. Most outcomes fit into the theme ‘an increase in knowledge and skill level,’ followed by ‘rise in environmental awareness,’‘facilitation of personal growth,’ and ‘enhancement of career development.’ Many structural experiences revealed may suggest the success of the program. The longer the participants had participated in the program, the more in-depth and diversified reflection of the senior participants relating to personal development were mentioned. This study provides critical insights into the validity of retrospective program evaluation for assessing the long-term impact of EfS programs by introducing a cross-sectional study of different cohorts as a serial time-point sampling strategy. Higher education institutions (HEIs) play a critical role in education for a just and sustainable future . Non-forAs Indeed, innovative teaching methods are needed to facilitate students’ learning and experience of concepts of sustainability and to foster a pro-sustainability attitude amongst them . In recePlanting a garden was cited by In higher education, GBL has commonly been adopted in non-formal contexts. This approach is appealing to HEIs, as it is effective in altering students’ attitudes without requiring them to possess prior gardening experience or high environmental motivation . With teSeveral characteristics of GBL make it a good model for EfS. The experiential nature of GBL is undoubtedly the most important component of any garden-related EfS program. Student-oriented or student-initiated programs can strengthen students’ problem-solving ability and arouse in them a sense of belonging to their university . The reaTo further enhance GBL on a university campus in Hong Kong, To nurture the pro-environmental awareness, attitudes and behavior of undergraduates at a university in Hong Kong with an ecogarden on campus, a non-formal co-curricular educational program was implemented at the university. GBL is the overarching pedagogy of this ongoing program, with nine sub-pedagogies , such asSeveral studies have focused on how long participants retain the impact of an environmental program  program at an HEI. A wilderness orientation program conducted at a university left a positive impact on the participants as long as 17 years after their graduation . Dvorak As Considering the very limited studies on the long-term effects of EfS programs at HEIs, the current cross-sectional study of participants from different cohorts aimed to evaluate the long-term (up to 4 years) effectiveness of an EfS program in nurturing participants’ pro-sustainability knowledge, skills and attitudes, by revealing the experience of the participants and its association with the program. A matrix matching the sub-pedagogies involved in the program with the outcomes observed in the participants was created to serve as a reference for other co-curricular GBL modules of higher education to be implemented in the future.per se  enrolled in the program, including both alumni and current students studying diverse educational  and non-educational major subjects  in four cohorts, were invited to take part in an online questionnaire survey. 32 participants completed online questionnaires were received, giving a response rate of 28%. The respondents of online questionnaire were consisted of 9 males and 23 females. To further explore the views of participants from different cohorts, follow-up semi-structured interviews were successfully conducted on twelve of the participants with 3 males and 9 females (three from each cohort), based on their preferences as indicated in the online survey. The majority (66.67%) of the interviewees studied education-related fields, including English Language Education and General Studies etc. The sample size is more than what The protocol of the study reported was approved by the Human Research Ethics Committee of the Education University of Hong Kong (Ref. No.: 2019-2020-0312). The participants were informed of all relevant information on the study before taking part. They understood their right to withdraw from the study at any time point if they chose not to participate. For the online questionnaire, all of the participants gave their consent to participate by proceeding from a consent statement shown in a webpage before filling out the questionnaire. For the video-conferencing interviews, written consent to take part in the study was obtained.Invitations to join the study were sent via the alumni and current students’ e-mail addresses, as registered on their first enrolment in the program. All of the participants were invited to complete an online questionnaire directed at collecting their views on the program. Demographic data, as well as information on self-perceived degree of participation in the program, given on a 5-point Likert scale (where 5 indicated the most active participation), were collected from the respondents. The other questions asked were all open questions aimed at understanding why the participants had joined the program, how the participants reviewed the program and what impact the program had had on the participants .In addition to the online questionnaire, follow-up semi-structured interviews were conducted on 12 students via online videoconferencing. Each interview lasted for 30 minutes. Any particular view on or impact of the program was further elaborated in these interviews. The interview questions were open-ended and were based on the responses to questions that the students had provided in the online questionnaire. The basic approach in the interview was to ask ‘Why’ and reveal more in-depth latent contents and impact from the students’ perspective. Some example questions are listed in Each interview was video-recorded, and the conversations were all transcribed. The text from both the online questionnaire and the transcription of the interviews was inductively analyzed according to the two data-analyzing approaches described below.We adopted the phenomenographic method of The process of categorization is iterative in nature. Refinement and modification, if needed, were taken place in order to generate a final set of categories, which would best represent the diversity of the participants’ experience. For the categorization, we follow the three requirements, the distinctness, parsimony and logical relationship of categories, as stated by The categorization was conducted by one experienced researcher. A second experienced researcher independently checked the coding and categorization and deliberated with the first researcher in cases of inconsistency. A third researcher was consulted if the inconsistency could not be resolved.The latent content in our conversations with the interviewees and their responses to the online survey were coded inductively. The codes were regarded as the experience related to the long-term program outcomes. They were reviewed, decontextualised, categorized, and reorganized into themes to explore any hidden or shared points of view and/or structures of the interrelated codes among different interviewees . EventuaAs for content analysis, the occurrences of the codes (outcomes) and themes were analyzed using the computer software NVivo 11 Pro. To elucidate the outcomes and thus the effectiveness of the program, the relationships among the codes and themes were referred to the documented psychological constructs.The data from the content analysis were shown in the form of descriptive statistics, with graphs constructed using the software GraphPad Prism 8. Maps showing the psychological constructs described by the participants were generated using VUE Version 3.3.0. The corresponding experiences of/pedagogies experienced by the participants in the program were also mapped on to those psychological constructs to synthesize a general model of the pedagogical devices used in the program and their respective outcomes.Four themes of outcomes could be categorized from both the questionnaires and the semi-structured interviews: ‘increase in knowledge and skill level,’ ‘rise in environmental awareness,’ ‘facilitation of personal growth,’ and ‘enhancement of career development,’ with miscellaneous outcomes being classified as ‘others,’ as revealed from both phenomenographic studies and content analysis. Based on the content analysis, on average, two to three codes per participant were mentioned by the respondents to the online survey. The codes recorded in the online survey were generally simple and superficial, without much elaboration and example illustration. The outcomes collected from the interviewees ranged from 8 to more than 20 codes per participant. The experienced shared by the interviewees appeared more in-depth and reflective, with more supporting examples.Albeit with the slight actual percentages difference between the online survey and videoconferencing interviews, the theme ‘increase in knowledge and skill level’ is the theme with the most codes, followed by the theme ‘rise in environmental awareness,’ ‘enhancement of career development,’ and ‘facilitation of personal growth’ .Within the theme of ‘increase in knowledge and skill level,’ the codes that could be recalled by the participants were essentially aligned with what had been taught in the training workshops. The subthemes identified included the knowledge on organic farming, aquaponics, ecology, environmental sustainability and energy, as well as, the skills on ecogarden management, farming, species identification, docent, presentation and classroom management for junior students .Most of the knowledge that the participants described was examples of system knowledge , such asThere were some examples of effectiveness knowledge, which were related to the facilitation of sustainability decision making, such as the importance of healthy soil, pest control and aquaponics. Interviewee 6 mentioned that “The practical skill (that I learnt) is the operation of an aquaponics equipment. I needed to consider water and other hardware. The ratio of fish to vegetables is important. For farming, I saw (learnt about) many tools, such as pots, hoes, and pesticides, and considered the weather (for farming) as well.” Systems-thinking competence was also reflected in the interviews. The response of Interviewee 10 stated that “(I learnt about) The relationship between the ecology of the insects, butterflies and plants in Hong Kong, their overall distribution in Hong Kong, the concept of farming, and the aquaponic system. I think it’s very comprehensive.”Within the environmental themes, the codes could be broadly classified into two subthemes attitudinal and behavioral changes , which wOn the attitudinal change, many participants have reflected the latent content about environmental empathy and attitude toward gardening , which wOn the behavioral change, actual change on knowledge enhancement such as “I have downloaded an app to understand different types of plants.” (Interviewee 5) and change to a more environmentally friendly behavior for instance “I tried to plant more. See whether I can create a similar program, as my home is adjacent to a farm.… We can also collect food waste in the school, and I have more awareness on it.” (Interviewee 7) were commonly recorded in the interviews. Some of the behaviors reported were not just restricted to the self-competence for environmental protection, but also on the influence to the surrounding people, “I can share my experience with others to promote organic farming and sustainable development.” (Online survey).It is worth-noting that many of the outcomes recorded, such as ‘develop a thankful heart,’ ‘being willing to work outdoors,’ ‘share ecological knowledge with friends,’ and ‘treasure food’ , were neThe content of the outcomes under the themes ‘Facilitation of personal growth’ varied from subthemes of becoming more considerate, independent and confident, to the subthemes on the willingness to strengthen students’ own social ties, accepting new challenges and even the attempt to live a simple lifestyle .For instances, Interviewee 2 gained a significant pleasant experience in teaching an ecogarden-based lesson which boosted up his self-confidence. “This was the first time I had taught a class of students. I had a bad experience when leading a tour in the Wetland Park (in the past). This time I did better and inspired my students to learn more. This increased my self-confidence as I had seldom talked in front of a large number of people before… I will not be shy anymore in the future, or in workplace, as well as other activities. I can have more ways to develop myself.”Becoming more open to accept new challenges were recorded in both the online survey and interviews, for example, “I became more likely to think and practice when facing new things.” (Online survey), “I have been more confident to step out of my comfort zone (after participating the program).” (Interviewee 11).New perspectives have been reflected by and introduced to the participants. A significant perceptual change on the interviewee’s ability to solve problem has been documented. Interviewee 1 described her experience as below “Using planting as an example, sometimes we think this crop cannot be grown, but actually it can grow very fast. We face different difficulties and need to try our best to face (and address) them.”All of the codes recorded under the theme of personal development were not explicitly taught or mentioned in the courses during the training stage of the program. Those were instead the outcomes that the students experienced implicitly from the program or generated upon reflection after graduating from the university.Similar to the theme on personal growth, the content of the outcomes under the themes ‘Enhancement of career development’  was not The codes under the subtheme ‘being teacher’ were commonly found in the participants, especially for those who were studying education major. “I will introduce myself (for having farming experience) when I obtain opportunities in teaching… Plant-related topic are usually covered in the curriculum of the primary school. I can inspire kids through this (ecogarden-related) knowledge if it fits the teaching plan. If not, I will show the content as supplementary knowledge.” Interviewee 5 reflected. She also made in-depth reflection about how the experience gained from the program facilitated her teaching: “I need to have more preparation as children would ask me many extra questions which are out of the books (during the tours).” Another online reply also mentioned that “Education in mainland China does not pay much attention to environmental education. So, (this experience) helped me (as a foreign student coming from mainland China) to prepare for teaching by using eco-garden as a tool (when I come back to China to teach).”On the subtheme ‘being farmer’, the main impacts of the program were to change the perception of the participants on the agriculture of Hong Kong and to equip the students with the necessary skills in farming. Interviewee 1 stated that “This (experience) affected my choice of firm for my placement. I wanted to further explore farming or eco-tourism.”Other themes such as mental health, sense of belonging to the universities were recorded. Volunteerism  was reflCodes about improving mental health were encountered more than once. Interviewee 1 mentioned about the function of planning in relieving her negative feeling. Data from the online survey also highlighted that “Irrigating plants in the eco-garden can help relieve my anxiety and depression.” Apart from getting rid of negative emotion, Interviewee 11 regarded the farming experience a very happy one. “I loosened the soil at university on a very hot day. When people passing by there, I was a bit embarrassed, and yet happy. The reason is that I like to do these things (farming)… And I will continue to do so.” There was one interesting finding from the interviews. Interviewee 5 particularly pointed out that “I have more interaction with parents about planting.” due to the development of common hobby in their leisure time with her parents.All of the nine sub-pedagogies were found to be related to the outcomes reported by the participants .Direct instruction, hands-on learning, nature-based learning and place-based learning were the sub-pedagogies most commonly associated with an increase in knowledge and skills . For exaField trips, hands-on learning, nature-based learning and place-based learning were more closely associated with the change in environmental awareness or attitude theme . InterviFor personal growth, collaborative learning was the sub-pedagogy related to most of the representative experiences, followed by hands-on learning, nature-based learning, place-based learning and service-based learning . InterviOn the career development, students gained authentic experience through direct instruction, nature-based, service-based and self-directed learning . InterviIn particular, place-based and service-based learning pedagogies, with the recognition of the symbolic role of the ecogarden for the university, seemed to nurture in the students a sense of belonging to the university. As shown before, Interviewee 3 stressed that “I am proud of myself for contributing to my university by serving at the pond (in the ecogarden)… My sense of belonging to the university was increased.”Examining the relationship between the learning experience (outcomes) under different themes and the cohort of enrolment based on content analysis, we can observe that more codes were recorded for the senior cohorts from the interview dataset , but notPhenomenographically speaking, reflections on personal growth coming from the senior cohort during interview were, indeed, more in-depth and diversified. For instance, Interviewee 1 coming from cohort of ‘16/’17 did not just discuss about the local agriculture, but also extended her awareness on the situation of agriculture in other area. “Organic farming is about eating crops in the right season… Understanding the scenarios involved in growing vegetables in China, such as the shortage of water in Yin Chuan, I thought further about sources of food and ways of farming.” She is also the one who expressed a deep reflection on her current living style and was eager to make a change, “Farmers live and work on farms without switching on air conditioners. I think that this kind of lifestyle is good. I am willing to try this simple life by living on the farm. I can try to have a lifestyle of “half farming, half working”.” Interviewee 2 from the same cohort could explain clearly how the experience gained from the program changed himself: “This was the first time I had taught a class of students. I had a bad experience when leading a tour in the Wetland Park (in the past). This time I did better and inspired my students to learn more. This increased my self-confidence as I had seldom talked in front of a large number of people before… I will not be shy anymore in the future, or in workplace, as well as other activities. I can have more ways to develop myself.” Interviewee 2 is also the one who ascertained the role of corporative learning in enhancing his social skill with clear justifications: “(I learnt) social skills, like how to cooperate with others through making teaching plans and discussion. This program required us to work together so that I could discover different problems when I worked on the tasks.”In contrast, the participants from junior cohort focused on more practical issues and environmental issues. For example, Interviewee 6 from cohort ‘18/’19 remembered the practical skill he learnt about aquaponics: “The practical skill (that I learnt) is the operation of an aquaponics equipment. I needed to consider water and other hardware. The ratio of fish to vegetables is important. For farming, I saw (learnt about) many tools, such as pots, hoes, and pesticides, and considered the weather (for farming) as well.” Interviewee 5 from the same cohort have downloaded an app to understand different types of plants.The students rated themselves to have deep engagement with the program did not demonstrate a higher number of recorded codes in both interview  and onliIn fact, Interviewee 5 who discussed in-depth how the program experience helped with her teaching duty has rated herself 4 out of the 5 Likert scale in terms of self-perceived participation: “I will introduce myself (for having farming experience) when I obtain opportunities in teaching… Plant-related topic are usually covered in the curriculum of the primary school. I can inspire kids through this (ecogarden-related) knowledge if it fits the teaching plan. If not, I will show the content as supplementary knowledge.” In contrast, Interviewee 6, who rated himself 2 out of 5 in participation, did not mention much on career development, despite of the fairly reflective content was recorded from him, e.g., “I have a thankful heart now, as different types of crops are not easy to grow. I eat different types of crops with gratitude now,” My deepest impression I gained about farming is that I was planting too many seeds, so they could not grow healthily. Different farming methods deepened my impression etc.From the phenomenographic perspective, the experience gained in the learning process could be “dissected” into referential and structural aspects . Han andBoth referential and structural aspects of experience could be identified in all the themes, and yet many of the online data seemed to be the referential ones, such as “(I learnt about) the campus’s ecology and biodiversity.” As shown by the dataset in the results, many structural aspects of experience were reflected by the interviewees. For instance, Interviewee 5 described how the experience in organizing teaching activity in ecogarden strengthened her competency in organizing similar activity in local school , Interviewee 1 extrapolated what she learnt about farming and local agriculture to comment on the agriculture oversea , Interviewee 6 recalled the requirements and conditions for aquaponic farming  etc.The participants’ in-depth reflections exhibiting various structural experience have provided evidence to prove the success of the program. The experience under the themes, ‘Facilitation of personal growth’ and ‘Enhancement of career development,’ which were not explicitly mentioned or taught in the workshop, in fact, hints on the possibility that factors other than curriculum, such as the diverse sub-pedagogies applied, the field-based and authentic service-based working environment etc., could facilitate the gaining of structural experience. The probability for the students to apply the learning experience in other personal context, such as Interviewee 5 practicing planting with her parents and applying her teaching experience in her own working school, would enhance the structural experience being extrapolated to external horizon.The curriculum developed in the current co-curricular program relied heavily on scientific, more specifically biological, content. This is in line with the review of A distinctive characteristic of the current program is the inclusion of training in presentation and docent skills, which has relatively rarely been mentioned in the literature. The usefulness of the knowledge and skills learnt by the participants to their career development was frequently acknowledged in the dataset. The success of this part of the training can be attributed to the abundance of opportunities for the participants to guide authentic tours during the practical internship stage.Compared with other studies adopting GBL, we found that the GBL approach induced all four types of outcome : (1) perApart from cognitive outcomes, we were able to identify affective responses from the participants, in particular from the interview data. We found evidence from the participants regarding the self-determination model of motivation . The stuRegarding the literature gaging the long-term impact of an EfS/EE program by retrospective assessment, the outcomes revealed by the current study were found to be comparable to psychological constructs or competencies found in other studies. We recorded experiences, such as ‘Increased social interactions,’ ‘Opportunities for personal growth,’ ‘More positive environmental attitudes,’ ‘Self-confidence,’ that have also been reported in previous studies . For insFocusing on HEIs, we identified competencies that resemble those elucidated by Our results not only echoed the findings of previous studies demonstrating the long-term effect of the EfS program, but also revealed a likely time-dependent increase in the codes under the personal growth theme after the completion of the program. Besides, the participants who did rate themselves as actively involved in the program reflected more content on the occupational theme. Indeed, none of the codes recorded in the personal growth and occupational themes, were found to be explicitly taught in the program.The more in-depth and diversified reflection of the senior participants implies that the participants had ‘discovered’ or ‘evaluated’ the outcomes of the program independently after joining the workforce in the community. It could be a results of a self-reflection on the part of the participants and metacognitive reflection on the experience that they had accumulated in the co-curricular program. The findings of this study suggested that, rather than taking place immediately after the participants’ completion of the program, this reflection may happen 3–4 years later, in their current occupation. The experience gained from the program resembles a seed planted in the heart of the participants and waiting to be nurtured for their career development and personal growth in the future. Indeed, the more senior participants provided more in-depth reflection not just on the outcomes related to personal growth but also environmental awareness and attitude.This study provides critical insight into the use of retrospective program evaluation to assess the long-term impact of EfS programs. Although this study was not a longitudinal study following the same batch of participants, its cross-sectional examination of different cohorts could serve as a serial time-point sampling approach. Compared with a cross-sectional study for a single cohort, this serial time-point sampling approach can provide more information on the outcomes of an EfS program in the long term. Certainly, the applicability of such an approach depends on whether the EE/EfS program examined was run repeatedly for cohorts. Indeed, many EfS programs are organized in a repetitive manner, which can be assessed by this approach.The hierarchical organization of the pedagogy of GBL with the sub-pedagogies implemented in the program provides a pedagogically diverse approach to nurture students. The outcomes described by the students for multiple sub-pedagogies imply that the pedagogies might operate in a collective, rather than an idiosyncratic manner. For example, the whole team of students serving in the ecogarden engaged in both collaborative and service-based learning. The students worked together to tackle all of the problems encountered during the management of the garden, gaining learning experience through problem-based, nature-based and collaborative learning. This organization of multiple sub-pedagogies may serve as a multi-pedagogical model or reference for future GBL or other place-related pedagogies.The non-formal nature of the program exerted no stress on the students. Such stress may interfere with students’ motivation to learn, as indicated in the findings. The 1-year program also gave the students plenty of time to gain experience. The ample time allowed enhanced relationship building among participants, as well as between the teachers and the participants. The close relationships between the members of the whole team (including the teachers) facilitated the overall management of the ecogarden. Indeed, an interviewee commented that she would like to meet the teachers of the program again, years after she had graduated.Moreover, the training provided by the program in both the cognitive and psychomotor domains, such as knowledge and skills in farming and presentation, facilitated the students’ career development, as suggested by the survey data. The benefits were particularly apparent for pre-service teachers. The alignment of learning content with what is needed for one’s potential career development is another important benefit of this program.The major limitation of the current study was the relatively small sample involved in the semi-structured interviews. Nevertheless, our findings indicate a relationship between the length of time since completing the program and the number of outcomes described that relate to personal growth, which warrants further comprehensive and vigorous study. The interplay between the experience accumulated in the GBL program and the potential for metacognitive reflection should also be studied further.To conclude, the study showed that the annual co-curricular ecogarden-based program in Hong Kong HEIs adopting GBL as the overarching pedagogy with diverse sub-pedagogies could sustain the knowledge and skills learnt by the participants for up to 4 years after the completion of the program. Furthermore, the program aroused environmental awareness and nurtured a positive attitude toward sustainability. The more senior a cohort of participants was, the more in-depth and diversified reflections they had on their personal growth. This result is probably related to the participants’ metacognition of the experience gained in the program during their current occupations. This study provides critical insights into the use of retrospective program evaluation to assess the long-term impact of an EfS program by introducing a cross-sectional study of different cohorts as a serial time-point sampling strategy.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher.The studies involving human participants were reviewed and approved by Human Research Ethics Committee of the Education University of Hong Kong (Ref. No.: 2019-2020-0312). The patients/participants provided their written informed consent to participate in this study.C-CC, K-HT, and W-CL were the project leaders and contributed to the conception of the study. C-CC was the corresponding author. C-CC, K-HT, and W-CL designed and implemented the co-curricular program with technical and logistical assistance from W-KN. W-KN collected most of the data. W-KN and Y-SW worked with C-CC on data analysis before the writing. All of the authors contributed to the manuscript revision and read and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Uncaria rhynchophylla, which have pharmacological effects such as antihypertension, anti-infection, and heart protection. An ultrahigh-performance liquid chromatography-mass spectrometry was established for the determination of hirsutine and hirsuteine in tissues , and their absorption, distribution, and metabolism were studied for providing information on its pharmacological mechanism. UPLC BEH C18 column  was used for chromatographic separation. The mobile phase was acetonitrile-0.1% formic acid, with a gradient elution, and the total run time was 4 min. Electrospray was used in the positive ion mode, and the multiple reaction monitoring (MRM) mode was for quantification. The acetonitrile precipitation method was used to remove protein-treated mouse plasma and tissue homogenate samples. In the concentration range of 2–5000 ng/g, hirsutine and hirsuteine in tissues showed good linearity (r > 0.995), and the lower limit of quantification was 2 ng/g. In the plasma and liver tissues, the interday and intraday precision of hirsutine and hirsuteine was less than 15%, the accuracy was between 90.9% and 110.1%, and the average recovery was better than 73.0%. The matrix effect was between 86.2% and 104.7%. The results showed that the precision, accuracy, recovery, and matrix effects meet the requirements for the study on the distribution of hirsutine and hirsuteine. After intraperitoneal administration of 10 mg/kg hirsutine and hirsuteine in mice, the distribution levels were highest in liver and kidney tissues, followed by the spleen and lung. Hirsutine and hirsuteine were low in brain tissue, but had obvious distribution, suggesting that they may pass through the blood-brain barrier.Hirsutine and hirsuteine were two alkaloid monomers extracted from the traditional Chinese medicine  Uncaria rhynchophylla（Miq.）Miq. ex Havil. is a commonly used Chinese medicine and belongs to the Uncaria Schreber nom. cons. [Uncaria rhynchophylla has an antagonistic effect on Ca2+, which can block external Ca2+ influx and release of internal Ca2+ [Uncaria rhynchophylla are the main active ingredients.m. cons. –3. Pharmnal Ca2+ . It has nal Ca2+ –7. It canal Ca2+ –12. The The distribution of drugs in the body is closely related to the pharmacological effects of drugs, and their distribution determines the strength and duration of the effect –15. It iTissue distribution is an indispensable part of pharmacokinetic research, and it can clarify the change trend of tissue drug concentration with time of administration, and then evaluate the targeting and tissue accumulation of the drug in the body, and judge the safety and effectiveness of the drug –18. In tHirsutine and hirsuteine (purity >98%) and diazepam  were purchased from Chengdu Munster Pharmaceutical Co., Ltd . Chromatographically pure acetonitrile, methanol, and formic acid were purchased from Tedia . Ultrapure water was prepared by a Millipore purification system . ICR mice  were provided by the Animal Experiment Center of Wenzhou Medical University.ACQUITY H-Class UPLC and XEVO TQS-micro Triple Quadrupole Mass Spectrometer . Masslynx 4.1 software (Waters Corp.) was used for data acquisition and instrument control.μm), and the column temperature was 40°C. The mobile phase consisted of 0.1% formic acid-acetonitrile, and the flow rate was 0.4 mL/min. The gradient elution procedure was: 0–0.2 min, acetonitrile 10%; 0.2–1.5 min, acetonitrile 10%–80%; 1.5–2.0 min, acetonitrile 80%; 2.0–2.5 min, acetonitrile 80%–10%; and 2.5–4.0 min, 10% acetonitrile.The chromatographic column was Waters UPLC BEH C18  m/z 285.1⟶193.3.The mass spectrometry parameters were set to a capillary voltage of 2.5 kV, a source temperature of 150°C, a desolvation temperature of 500°C, and nitrogen as the desolvation gas (900 L/h) and cone gas (50 L/h). The MRM mode was used to quantitatively analyze hirsutine m/Hirsutine and hirsuteine were accurately weighed into 10 mL volumetric flasks, and hirsutine and hirsuteine (1.0 mg/mL) stock solution was prepared with methanol-water (50 : 50). Diazepam was accurately weighed into a 10 mL volumetric flask, and a diazepam (1.0 mg/mL) stock solution was prepared with methanol-water (50 : 50). The stock solution was diluted with methanol to a working solution of various concentrations, stored in a refrigerator at 4° C, and kept at room temperature during use.μL of internal standard (50 ng/mL) acetonitrile was added. After vortexing for 1.0 min, it is placed in a low-temperature high-speed centrifuge  for 10 min. Then, 150 μL of the supernatant is taken and placed it in a cannula into a sample bottle, and 2 μL is taken for injection for UPLC-MS/MS detection.Tissue samples are taken out of the refrigerator and thawed. The tissue is ground and then weighed (50 mg). The weighed tissue was placed in a 1.5 mL centrifuge tube, and 200 Proper amount of hirsutine and hirsuteine working solution is added to blank tissue  to prepare hirsutine and hirsuteine standard curve. The concentration is in the range of 2–5000 ng/g, and the concentrations are 2, 5, 20, 100, 200, 500, 1000, 2000, and 5000 ng/g. In the same way as the standard curve, quality control samples (QC) were prepared at three concentrations .For the analysis of blank tissue and blank tissue spiked with hirsutine, hirsuteine, and internal standard, tissue samples were administered intraperitoneally at 10 mg/kg in mice to evaluate the selectivity of the method.Standard working solutions were prepared into different standard series with standard concentrations ranging from 2 to 5000 ng/g. Under the same conditions as the tissue samples to be measured, the peak area of each peak is measured, and the ratio of the peak area to the internal standard peak area is used to draw a standard curve for the sample concentration.Precision and accuracy were assessed by measuring tissue samples of these three QC sample concentration levels  in 6 replicates. Intra- and interday precision is determined by measuring QC samples at three concentration levels for three consecutive days. The intraday and interday accuracy were determined by measuring the consistency of the average value of the QC samples at three concentration levels with the true value for three consecutive days.The recovery was evaluated by comparing the measured peak areas of low, medium, and high concentration QC samples with the corresponding standard peak areas. The peak areas obtained by preparing blank plasma or tissue after sample processing and adding standard solutions to prepare low, medium, and high concentrations  were compared with the corresponding standard peak areas by using acetonitrile-0.1% formic acid  to assess matrix effects.The mouse QC samples were analyzed at low, medium, and high concentrations  by placing them in three storage conditions to investigate trichostine and dehydropilus in mouse plasma or tissue, respectively. Stability in injection vials, short-term stability (2 hours at room temperature), long-term stability , freeze-thaw stability (−20°C to room temperature), and 3 concentrations of freshly prepared  standard samples were compared for peak area to investigate stability.Thirty mice were injected intraperitoneally with 10 mg/kg hirsutine and hirsuteine, and then at 0.25, 0.5, 2, 4, 6, and 12 h, with 4% chloride, 5 mice were sacrificed after being subjected to aldehyde anesthesia, and tissue samples were collected . After collection, the surface was washed with ice-cold saline and dried with filter paper. Tissue samples were then stored at −20°C.z 369.2⟶226.0 for hirsutine, and m/z 367⟶169.9 for hirsuteine.Electrospray ESI positive and negative electrode selection was often evaluated in methodological studies . In thisμm) can obtain satisfactory peak time and peak shape. We also tried different mobile phases, such as acetonitrile-water, methanol-water, acetonitrile-0.1% formic acid, and methanol-0.1% formic acid, and found that the peak shape and sensitivity of acetonitrile-0.1% formic acid were the best. Therefore, a BEH C18  column was used in this work, and acetonitrile-0.1% formic acid was used.HPLC conditions were as far as possible from separating endogenous interfering substances from analyte and internal standard, and the chromatographic behavior of the column and mobile phase plays a decisive role –22. BEH μL acetonitrile precipitation. As a result, it was found that the direct protein precipitation method can obtain acceptable extraction recovery and matrix effect.Prior to UPLC-MS/MS analysis, removal of proteins and potential interference was a key point in method development –25. In oIn the concentration range of 2–5000 ng/g, the peak area ratio and concentration linearly regress. The linear equations of various tissues are shown in The data in Mouse tissue samples were tested at room temperature for 2 hours, at −20°C for 30 days, and freeze-thaw stability tests were also conducted. The results showed that the variation of hirsutine and hirsuteine was within ±15%, and RSD was within 15%, indicating that they were stable.After intraperitoneal injection of 10 mg/kg hirsutine and hirsuteine to mice, the mean time distribution curve of tissues are shown in μL plasma, and needed 4 min for one sample [μL plasma [μL plasma or brain [Although some literature studies have reported the pharmacokinetics of hirsutine or hirsuteine in rats –29, no le sample . Wu et aL plasma . KushidaIt was rapidly distributed in various tissues and organs through blood circulation, and the highest level was distributed in liver and kidney tissues, followed by spleen and lung. This phenomenon indicates that it was widely distributed in mice, which may be related to the higher lipid solubility of hirsutine and hirsuteine. With the extension of the administration time, the drug concentrations of hirsutine and hirsuteine in each tissue decreased rapidly, and the concentration of each tissue was already low at 6 h. The highest concentration is in liver and kidney tissues. Metabolism of hirsutine and hirsuteine mainly occurs in liver tissues, which were excreted in renal tissues, and may be related to large blood flow and good circulation in liver and kidney tissues. Hirsutine and hirsuteine are low in brain tissue but have obvious distribution, suggesting that the drug may pass through the blood-brain barrier.We established a method based on UPLC-MS/MS for the detection of hirsutine and hirsuteine in tissues, with a linear range of 2–5000 ng/g. The UPLC-MS/MS was simple and sensitive, and 50 mg of tissue was required. After mice were injected intraperitoneally with 10 mg/kg hirsutine and hirsuteine, the distribution levels were highest in liver and kidney tissues, followed by spleen and lung. The results of this study also help to better understand the pharmacological mechanisms of hirsutine and hirsuteine.


Irritable bowel syndrome (IBS) is a common chronic medical condition, in both children and adults. Despite the availability of effective (non)pharmacological treatments, symptoms persist in a significant amount of patients with IBS. Faecal microbiota transplantation (FMT) may be an effective alternative treatment in adolescents with refractory IBS through manipulation of the intestinal microbiota.This randomised, placebo-controlled single-centre pilot study will assess feasibility and efficacy of FMT in 30 adolescents (16–21 years) with refractory IBS. Patients will be randomly allocated (1:1) to receive two allogeneic  or two autologous (own) faecal infusions at baseline and after 6 weeks. Primary outcomes will assess feasibility, including patient and donor recruitment, adherence and incidence rates of adverse events. To evaluate clinical efficacy, secondary outcomes will include the proportion of patients with at least >50% reduction of their abdominal pain intensity and frequency 12 weeks after the first FMT, and after 6-month and 12-month follow-up. Other outcomes comprise changes in faecal gut microbiota composition, quality of life, depression and anxiety, school or work absenteeism and adequate relief, measured directly after FMTs and after 6 and 12 months of follow-up.This randomised controlled trial will investigate the feasibility and effectiveness of repetitive FMTs in adolescents with refractory IBS.The study is approved by the Medical Research Ethics Committees AMC (MEC-AMC) in the Netherlands.NCT03074227. It is suggested that irritable bowel syndrome (IBS) symptoms are generated through an effect of the microbiome on the intestinal barrier, enteroendocrine system, the immune system and the gut–brain axis.Faecal microbiota transplantation (FMT), administered via a nasoduodenal tube, is a new treatment regimen which modifies the gut microbiome through replacement of the patient microbiome by that of a healthy donor.This randomised controlled trial will investigate the feasibility and effectiveness of repetitive FMTs in adolescents with refractory IBS.This study will enable us to analyse in detail which microbiota components might predict a positive response to FMT.Irritable bowel syndrome (IBS) according to the Rome IV criteria  is a com9 10Box 1Abdominal pain at least 4 days per month associated with one or more of the following:Related to defecationA change in frequency of stoolA change in form (appearance) of stoolIn children with constipation, the pain does not resolve with resolution of the constipation .After appropriate evaluation, the symptoms cannot be fully explained by another medical condition.*Criteria fulfilled for at least 2 months before diagnosis.Clostridium difficile infectionStandard medical care for IBS consists of education, reassurance and simple dietary and behavioural advices.The Faecal Administration in refractory Irritable bowel Syndrome trial is a double-blind, randomised, placebo-controlled single-centre pilot study. We aim to enrol 30 adolescents aged between 16 and 21 years, with refractory IBS . After rBox 2IBS according to the Rome IV criteria.Symptoms are present for ≥12 months.Patients received adequate explanation, reassurance and dietary advice for their symptoms.There is an absence of response to a minimum of six sessions of psychological treatment, like hypnotherapy or cognitive–behavioural therapy.There is an absence of response to an adequate dose of at least one pharmacological agent tried for a minimum of 6 weeks.There was no involvement of patients or the public in the design of this RCT.Patients from the outpatient clinic of the Amsterdam University Medical Centre (AUMC) will be recruited by their treating gastroenterologist. Furthermore, patients from other hospitals can be referred to the AUMC for participation in this study. In addition, patients will be recruited throughout the Netherlands with help of online advertisement through IBS patient associations. Patient enrolment began in September 2018.Healthy faecal donors will be recruited through advertisement in the form of posters, intranet network and emails, and via word by mouth.Eligible patients will be invited for a screening visit. Informed consent from the participants will be obtained by the clinical research coordinator. During the screening visit, adolescents will undergo routine laboratory testing to exclude underlying organic disorders . FurtherPotential donors will be thoroughly screened according to the screenings protocol of the Netherlands Donor Faeces Bank.Age 16–21 years.Non-smokers.Ability to give informed consent.IBS diagnosis .Refractory symptoms .Average daily pain rate ≥30 mm on the pain component scale of the Irritable Bowel Syndrome Severity Scoring System (IBS-SSS).33Exclusion criteria are presented in 10.1136/bmjpo-2020-000689.supp1Supplementary dataAge≥16 years.Non-smokers.Ability to give informed consent.2.Body mass index 18–25 kg/mRegular morning stool pattern.Exclusion criteria are presented in Randomisation will be done by a computerised random-number generator in the Electronic Data Capture system Castor EDC in a 1:1 ratio to one of the following two treatment arms:Allogeneic faecal infusions at t=0 weeks and t=6 weeks.Autologous faecal infusions at t=0 weeks and t=6 weeks.Randomly permuted blocks of size 2 and 4 will be used with no stratification. On the day of faecal transplantation, both patient and donors will deliver faeces produced that morning. Randomisation will be performed by one of the ‘randomisation assistants’, who is designated to this task. To guarantee blinding, the randomisation assistant will make sure the randomised treatment is not traceable to the donor or the patient. The blinded faeces will be brought to the laboratory, where the preparation of the faeces will be done by one of the investigators. Detailed information about the preparation process is outlined under ‘FMT procedure’. During the second FMT at 6 weeks, faeces will be processed according to the randomisation performed on the first transplantation day. The randomisation assistant is the only person who will know which treatment the patient will be given and will have no role in further parts of the study. The randomisation list will be kept under secured access by Castor EDC. In case of an emergency, the study treatment can be unblinded after consultation of the principal investigator.At baseline and at 6 weeks, patient and donor will collect a fresh morning stool sample in a small container and bring this to the AUMC for processing. On arrival of the patient in the hospital, a nasoduodenal tube will be positioned under direct imaging, with the Cortrak electromagnetic sensing device.On the day of infusion, a fresh faeces sample (100–200 g on average) of either the donor  or patient (autologous) will be used. In case a patient is not able to provide a fresh morning faeces sample, the first faecal production after the start of bowel lavage with Klean-Prep is used as suitable faecal sample for further processing. Time of collection will be recorded. The faeces will be weighted and mixed with 200–400 mL saline (0.9% NaCl) until fully homogenised. Next, the faeces solution is poured through a double gauze and debris of large size will be removed. This step will be repeated. Afterwards, the homogenised solution will be decanted through a metal funnel into a 200 ml sterile plastic bottle. All steps are performed under a fume hood by one of the coinvestigators. Within 6 hours after production by the donor, the faeces will be installed through the nasoduodenal tube in the patient.All below-mentioned outcome measures apply to patients.The primary objective of this RCT is to assess the feasibility of our study protocol. This will be assessed by evaluating the process of patient recruitment and screening, the patient drop-out rate and the incidence rates of adverse events (AEs). Secondary objectives include the proportion of patients with >50% reduction of their abdominal pain intensity and pain frequency compared with baseline at t=12 weeks after the first FMT. This will be assessed with the pain component of the IBS-SSS.Since this is a pilot study, a reliable sample size calculation is not feasible. In accordance with recruitment recommendations,All data will be analysed according to the intention-to-treat principle. Feasibility outcome measures will be presented as proportions at each time point throughout the trial. To assess the efficacy outcomes group differences will be calculated by a mean difference with a 95% CI, using an independent t-test for continuous variables with a parametric distribution or Mann-Whitney U test for continuous variables with a non-parametric distribution. Group differences for categorical variables will be calculated using Fisher’s exact statistics. In addition, data of continues variables will be analysed using mixed models to account for correlations of measurements within the same individual on several time points. Due to the small sample size, baseline values will not be incorporated in these analyses. Significance is set at α=0.05 in all analyses.Microbiota composition of the faecal samples will be measured by 16S rRNA sequencing and specific genera/species are screened by qPCR. Alfa and beta diversity of faecal samples will be calculated. Cluster analysis and similarity of the microbiota profiles, expressed as Pearson correlation, will be assessed and compared between patients with IBS and healthy donors, between treatment groups and between responders and non-responders. In addition, short-chain fatty acids composition of the faecal samples will be measured.In order to optimise safety of the study during inclusion, patient data will be disclosed to a data safety monitoring board (DSMB) when 50% of the intended sample size is attained and has reached 12 weeks follow-up. The advice(s) of the DSMB will be notified on receipt by the sponsor to the METC  that approved the protocol. With this notification, a statement will be included indicating whether the advice will be followed.The risks associated with participation in this RCT can be considered moderate, because of the minimal invasive treatment. Nasoduodenal tube positioning through a Cortrak electromagnetic sensing device carries a little risk of complications like aspiration, perforation or malpositioning. If there is any doubt of malposition of the tube, a plain abdominal X-ray will be performed. To prevent complications, patients with swallowing disorders will not be included in this study.Recent meta-analyses on clinical outcomes of FMT in general concluded that no serious AEs were attributable to FMT.On 23 November 2017, the first study participant (in particular donor) was included in the trial. Until today, 58 potential donors were recruited of which 39 were included and started the screening procedure. Finally, a total of five donors were eligible to donate faeces. The first patient signed informed consent in August 2018. At time of writing, 15 adolescents were recruited and a total of 19 faecal transplantations have been performed.IBS is a chronic and disabling condition, which can pose great impact on daily life of patients, reflected in decreased quality of life,23Up to now, six RCTs have been performed to assess the effect of FMT in IBS in adults. Two trials assessed the effect of FMT administered by capsules, two evaluated the effect of FMT delivered by colonoscopy, one via gastroscope and one by nasojejunal tube.30The present pilot study assesses the feasibility of FMT in adolescents with refractory IBS according to the Rome IV criteria. Furthermore, the efficacy of FMT on abdominal pain symptoms in these patients is explored. By designing this specific treatment protocol, a unique opportunity is created to investigate potential beneficial effects of restoring the gut microbiota composition on abdominal pain problems. Data of this study will help determine optimal study conditions and inform the choice of endpoints for future, larger size, double-blind RCTs on FMT in adolescents with IBS. Furthermore, this study will define preliminary efficacy results of the use of FMT in these patients. In addition, this study will enable us to analyse in detail which microbiota components might predict a positive response to FMT.Our study has several strengths. First, the FMT will be administered via a nasoduodenal tube and it will be performed twice, since it has been demonstrated that this might enhance the effect of the FMT.A limitation of our study is the small sample size, which allows us to only encounter major effects of the FMT treatment. Furthermore, we decided to include patients with IBS regardless of subtype, leading to a heterogeneous patient population which may affect the efficacy results. Moreover, it is unclear what the effect of bowel lavage is on the efficacy of FMT and on microbiome composition. Studies with and without bowel preparations before FMT demonstrate great efficacy.In conclusion, the results of this trial will provide preliminary evidence for the use of FMT in adolescents with refractory IBS. The results will inform future larger, double-blind, placebo-controlled trials on the right sample size, on the feasibility of this study design, on efficacy outcome measures and on the potential of the microbiome to be a therapeutic target in IBS.


Rotating hinge knee prostheses are typically used in revision and severe primary total knee arthroplasty (TKA). For these challenging patient groups, currently only few studies with mid- or even long-term follow-up and adequate patient numbers are available. In addition, a more specific definition is needed of the indications for a rotating hinge prothesis in primary patients beyond the use in bone defects.  In this prospective study, 170 primary and 62 revision TKA patients were included who received a rotating hinge knee prosthesis at the study centre between the years 2009 and 2014. Of these, 98 primary and 22 revision TKA patients were available for 5-year functional and clinical follow-up examinations. Prosthesis survival in both patient groups could be compared up to a 9-year follow-up.  Postoperatively, functional results including range of motion (ROM) and clinical scores like the Oxford Knee Score (OKS) and subscales of the Knee Society Score (KSS) improved better in patients treated for primary knee arthroplasty than for revision patients. Besides the patient group (primary vs. revision TKA), no overall influencing factors  regarding functional results could be identified in a multiple linear regression analysis. The revision rate of primary patients was significantly lower than in the revision patients, with an 8-year Kaplan-Meier prosthesis survival of 88% in the Primary and 60% in the Revision group.  The prosthesis provides promising results in severe primary and revision knee arthroplasty. In addition to commonly agreed recommendations regarding the use of rotating hinge knee prostheses for primary surgery, six specific indications are proposed and discussed here as a base for scientific debate. Total knee arthroplasty (TKA) is a frequently performed surgery with an increasing number of interventions , 2. The In the beginning, hinged knee prostheses were only designated for severe revision cases and salvage therapy. Today, the deployment of a rotating hinge prosthesis also in primary TKA is a matter of debate amongst the orthopaedic society , 11. ConIn this publication, functional and survival results of the EnduRo rotating hinge prosthesis are presented from a prospective patient cohort. The hypothesis was that EnduRo obtains reliable results in primary and revision TKA patients. Short-term results of a part of this patient cohort and a second study centre were already published by Giurea et al. , when a This study was a prospective single centre study, performed according to the Declaration of Helsinki. Eligibility criteria were limited to patients in the clinic of the principal investigator treated with the EnduRo rotating hinge prosthesis for primary or revision TKA for all indications except bone tumours. Between March 2009 and February 2014, 290 patients were treated with the prosthesis in the clinic of the principal investigator; thereof 232 patients could be included into the study. Patients were contacted annually for follow-up examinations . At time of the 5-year follow-up, the number of patients discontinuing the study due to withdrawal, revision, loss to follow-up, death, and other reasons was 72 patients in the Primary group and 40 patients in the Revision group see . At studThe modular rotating hinge prosthesis system EnduRo  was used in all patients. The hinge mechanism is not primary weight bearing as force is transmitted from the femoral component to the tibial component via the polyethylene insert with high contact area. An offset option and wedges for the tibial and femoral components are available to cover specific anatomical characteristics. As a unique feature, EnduRo contains flanges and bushings that are made of carbon-fibre reinforced poly-ether-ether-ketone (CFR-PEEK) .All surgeries were performed by four orthopaedic expert surgeons; the majority (91 of 120 patients) was performed by the principal investigator (Hans-Joachim Neuhaus). Surgeries were performed according to the procedure described by Giurea et al., and the method description partly reproduces their wording . BrieflyIn addition to the documentation of baseline demographic data, medical history, and perioperative assessment, a yearly follow-up of the patients was carried out, which is at time of this report still ongoing until a planned physical follow-up examination after 10 years.Physical examinations were performed at the time points 1, 2, and 5 years in the outpatient department of the principal investigator's clinic. All other yearly follow-up time points were conducted by telephone interview only. The 5 year follow-up was completed in 2019. Primary outcomes obtained during follow-up were functional and clinical results. These were assessed using the knee (kKSS) and functional (fKSS) KSS subscales , the OKSThe revision rate was defined as secondary outcome variable. Complications resulting in revisions were categorized into 3 types according to Giurea et al. and Böhler et al. , 17. TypSurvival data  were collected to the best of our knowledge, also in case of deceased patients or patients who were not able or not willing to participate in the yearly phone interviews. All survival-related data until database lock in 2019 were included into revision analysis and Kaplan-Meier calculation. Ethical approval was received from the regional institutional review board, and all patients provided written informed consent.t-tests were used for comparison of continuous outcomes between groups; differences were considered significant at p values below 0.05. As all analyses were explorative, this level does not apply in a confirmative sense, and no multiplicity adjustments were made.Statistical analysis was performed using the SAS software version 9.4 . Patients with completed 5-year follow-up were included in the analysis of functional and clinical outcome. p = 0.05. All survival-related data which were available until the time of completion of the 5-year follow-up were included for calculation of survival rates.Kaplan-Meier method was used for analysis of the prosthesis survival rate; point-wise 95% confidence intervals were calculated according to Agresti and Coull . PatientMultiple linear regression repeated measure models with prespecified set of impacting variables were used to analyse the risks for continuous outcomes. The variable set consisted of age, gender, BMI, baseline score, visit ID, and patient group (primary vs. revision TKA).Of the 170 primary and 62 revision TKA patients which were prospectively included in the study, 98 primary and 22 revision TKA patients were still available for the 5-year follow-up examinations. For the analysis of survival rates, additionally data from the yearly telephone follow-up time points of up to 9 years were used.Patient characteristics of both groups are provided in The main indication in the Revision group  was instThe performance of the prosthesis was assessed using ROM, functional, and clinical scores. Results of the Primary and Revision groups in terms of ROM, OKS, fKSS, and kKSS are provided in p ≤ 0.05) at all time points. Conclusively, compared to the preoperative state, the implantation of EnduRo achieved an improvement of ROM, OKS, kKSS, and fKSS values, with better results in the Primary than in the Revision group.No statistically significant difference was present between Primary and Revision groups for preoperative ROM, OKS, and kKSS, whereas preoperative fKSS was significantly lower in the Revision group compared to the Primary group. Postoperatively, ROM was significantly higher in the Primary group only 1 year postoperatively, whereas all other scores were significantly higher in the Primary group in comparison to the Revision group  was performed see . In addiRevision was defined as exchange of one or more prosthesis components, excluding patella resurfacing due to secondary retropatellar arthrosis and prophylactic exchange of polyethylene components. At database lock in 2019, which corresponds to a mean follow-up of 57.1 and 43.7 months of the Primary and Revision group, 15 primary patients  and 13 revision patients (20%) had to be revised see .Complications resulting in revision were categorized into type 1, infection; type 2, periprosthetic complications ; and type 3, implant complications .The most frequent reason for revision in the Primary group was infection (7 patients) and patella-related problems (4 patients). Type 3 complications in the Primary group included aseptic loosening and instability (1 patient each).In the Revision group, six patients were revised due to infection, six patients were revised due to aseptic loosening, and one patient was revised due to poor function.p = 0.0004).Kaplan-Meier analysis was performed to assess survival of the prosthesis in the Primary and Revision group. Survival probabilities after 1 year in the Primary and Revision group were 93% and 91%, respectively see . Values The most important finding of the current study is that the EnduRo rotating hinge system achieves good results in primary and revision TKA. Comparison between the Primary and Revision group showed better postoperative functional results and survival rates in the Primary group.Böhler et al.  presenteOchs et al. presented the results of primary and revision TKA with EnduRo, which was implanted using a navigation system . In thisFurther studies directly comparing the functional results of rotating hinge prostheses in primary and revision TKA are rare and based on small patient cohorts. Efe et al. found no significant differences of kKSS, fKSS, and ROM in primary and revision TKA treated with Endo-Modell . However, there were clearly more complications and a lower survival rate in the Revision group . In anotIn the current study, the revision rate of the Revision group was about twice as much as that of the Primary group. In the Primary group, the most prevalent type of complications was infection, followed type 2: periprosthetic complications, especially patella problems. Type 1 and type 2 complications are not directly associated with the prosthesis itself but rather with the surgical technique and tissue quality , 17.Revision was necessary in 9.7% of the Primary group patients and 20% of the Revision group patients after 9 years. Failure probability of hinged knee prostheses in the EPRD after 4 years is just below 7%, whereas for standard nonconstrained TKA it is about 3.5% . The AusIn the study by Efe et al. with a mean follow-up of 56 months of 21 primary TKA and 28 revision TKA cases with rotating hinge prothesis Endo-Modell , (re-)revision rates of 5% in primary and 24% in revision TKA were reported . LikewisIn the current study, the major reasons for revision in the Primary group were infection and patella problems, whereas re-revision in the Revision group was mostly necessary due to infection and aseptic loosening. In the EPRD, aseptic loosening and infection are the most prevalent causes for revision of primary TKA with 24% and 14.5% . LikewisAnother important point regarding the learning curve concerns the preoperative planning of the tibia and femur stems. During this critical step, it has to be assessed whether the scheduled stem fits the intramedullary canal. Especially in older patients, the bone may be deformed, resulting in a curved intramedullary canal. In these cases, a too long stem would make excessive contact with the cortical bone, inducing high levels of stress and bone remodelling, which can eventually cause aseptic loosening. If preoperative planning shows that a cementless stem cannot be implanted without too much contact with the cortical bone, a short cemented stem is chosen. This stem is implanted eccentric in a large diameter hole, which is filled with bone cement to prevent cortical bone overstressing.In the study patients, no case of loosening due to shearing forces on the prosthesis was observed. This may be attributed to our surgical technique regarding the collateral ligaments: We do not trim the collateral ligaments but rather peel them from the femoral epicondyle before implanting the prosthesis. Afterwards, the collateral ligaments place back into position on the epicondyles and grow onto them (which we see in patients where early reoperations were required). Our hypothesis is that the ongrown collateral ligaments partially gain back function and therefore reduce shearing forces on the prosthesis. This technique and the potential partial recovery of function of the collateral ligaments may contribute to the improvement of functional results up to the two-year follow-up.This study has some limitations. First, there was a high number of patients who dropped out of the study, and some of the patients did not participate in all follow-up examinations. However, the number of included patients was sufficient for statistical analysis. If possible, the implantation status of patients who were not able or not willing to participate and of deceased patients was documented for the calculation of survival. However, the number of revisions may still be underestimated. Second, the period in which the index surgeries were performed is rather long. Therefore, the effects of a learning curve are included in this study. Third, the reasons for revision surgery are very specific and may have an influence on the results in the Revision group. However, from a statistical perspective, it was not reasonable to study this influence. Fourth, the study was performed with a specific rotating hinge prosthesis brand, and the transferability of the results to other rotating hinge knee systems in general has to be proven.Although the EnduRo prosthesis is intended for revision surgery or primary TKA with bone defects, in our clinic, it is frequently used also for primary TKA with specific indications. These include excessive varus (≥20°) and valgus (≥15°) deformities and ligamentous instability, especially instability of the medial collateral ligament, which is in line with current publications , 30.Insufficient Posterior Cruciate Ligament. During preparation of the tibia for a cruciate-retaining prosthesis, there is a distinct risk of injuring the root of the ligament, especially with increasing tibial slope [al slope Severe Extension or Flexion Deficit (≥20°). Extension deficits may be induced by fibrotic changes of the dorsal capsule [ capsule . In suchKnees Designated for Unconstrained TKA, Which Cannot Be Balanced Intraoperatively by Navigation Technology. Intraoperative switch to a rotating hinge prosthesis is performed to achieve a well-stabilized postoperative resultRheumatic Patients. Bone and soft tissue quality is often compromised, and ligaments are frequently insufficient, so that stability can only be achieved via constrained prostheses on the long termPatients with Neurologic Disorders, Especially Spasticity. The need for TKA often derives from an inability to stabilize the joint; therefore, more constrained prostheses shall be used from our point of view to obtain sufficient stability, especially on the long termObese Patients. It was shown that in flexion extreme forces are transmitted to the distal femoral bone, which may result in loosening at the bone-implant interface [nterface , 34. A rFurther specific indications are proposed from the point of view of the first author and presented below:We aim to highlight our specific views as a base for scientific debate. It has to be considered that rotating hinge TKA has higher complication and lower survival rates in comparison to unconstrained TKA. Furthermore, revision of a rotating hinge prosthesis is more challenging than revision of unconstrained TKA. Therefore, the benefits and potential disadvantages of such a treatment have to be weighed carefully for each patient, and preoperative planning has to be accomplished accurately. In all cases, the least invasive option of the rotating hinge prosthesis system is chosen, with short stems and cementless fixation with rather gliding-fit than press-fit anchorage.To the best of our knowledge, the current study includes the largest patient cohort at a 5-year follow-up for the direct comparison of rotating hinge prostheses for primary and revision TKA regarding functional results. In addition, survival data are presented with a maximum follow-up of nine years. Therefore, this study has an impact on the scientific assessment of the controversy topic of rotating hinge knee prostheses for primary TKA.In conclusion, the rotating hinge prosthesis system provides good medium-term results in severe primary and revision TKA. Functional results significantly improved compared to the preoperative state. In primary TKA patients, significantly better functional results and survival rates were obtained than in revision patients. Specific indications for primary TKA with rotating hinge prostheses are presented and act as a base for scientific discussion.