Systematic identification of genotype-dependent enhancer variants in eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is a rare atopic disorder associated with esophageal dysfunction, including difficulty swallowing, food impaction, and inflammation, that develops in a small subset of people with food allergies. Genome-wide association studies (GWASs) have identified 9 independent EoE risk loci reaching genome-wide significance (p < 5 × 10-8) and 27 additional loci of suggestive significance (5 × 10-8 < p < 1 × 10-5). In the current study, we perform linkage disequilibrium (LD) expansion of these loci to nominate a set of 531 variants that are potentially causal. To systematically interrogate the gene regulatory activity of these variants, we designed a massively parallel reporter assay (MPRA) containing the alleles of each variant within their genomic sequence context cloned into a GFP reporter library. Analysis of reporter gene expression in TE-7, HaCaT, and Jurkat cells revealed cell-type-specific gene regulation. We identify 32 allelic enhancer variants, representing 6 genome-wide significant EoE loci and 7 suggestive EoE loci, that regulate reporter gene expression in a genotype-dependent manner in at least one cellular context. By annotating these variants with expression quantitative trait loci (eQTL) and chromatin looping data in related tissues and cell types, we identify putative target genes affected by genetic variation in individuals with EoE. Transcription factor enrichment analyses reveal possible roles for cell-type-specific regulators, including GATA3. Our approach reduces the large set of EoE-associated variants to a set of 32 with allelic regulatory activity, providing functional insights into the effects of genetic variation in this disease.

Neuronal vulnerability and multilineage diversity in multiple sclerosis.

Multiple sclerosis (MS) is a neuroinflammatory disease with a relapsing-remitting disease course at early stages, distinct lesion characteristics in cortical grey versus subcortical white matter and neurodegeneration at chronic stages. Here we used single-nucleus RNA sequencing to assess changes in expression in multiple cell lineages in MS lesions and validated the results using multiplex in situ hybridization. We found selective vulnerability and loss of excitatory CUX2-expressing projection neurons in upper-cortical layers underlying meningeal inflammation; such MS neuron populations exhibited upregulation of stress pathway genes and long non-coding RNAs. Signatures of stressed oligodendrocytes, reactive astrocytes and activated microglia mapped most strongly to the rim of MS plaques. Notably, single-nucleus RNA sequencing identified phagocytosing microglia and/or macrophages by their ingestion and perinuclear import of myelin transcripts, confirmed by functional mouse and human culture assays. Our findings indicate lineage- and region-specific transcriptomic changes associated with selective cortical neuron damage and glial activation contributing to progression of MS lesions.

Shared and distinct interactions of type 1 and type 2 Epstein-Barr Nuclear Antigen 2 with the human genome.

BACKGROUND: There are two major genetic types of Epstein-Barr Virus (EBV): type 1 (EBV-1) and type 2 (EBV-2). EBV functions by manipulating gene expression in host B cells, using virus-encoded gene regulatory proteins including Epstein-Barr Nuclear Antigen 2 (EBNA2). While type 1 EBNA2 is known to interact with human transcription factors (hTFs) such as RBPJ, EBF1, and SPI1 (PU.1), type 2 EBNA2 shares only ~ 50% amino acid identity with type 1 and thus may have distinct binding partners, human genome binding locations, and functions. RESULTS: In this study, we examined genome-wide EBNA2 binding in EBV-1 and EBV-2 transformed human B cells to identify shared and unique EBNA2 interactions with the human genome, revealing thousands of type-specific EBNA2 ChIP-seq peaks. Computational predictions based on hTF motifs and subsequent ChIP-seq experiments revealed that both type 1 and 2 EBNA2 co-occupy the genome with SPI1 and AP-1 (BATF and JUNB) hTFs. However, type 1 EBNA2 showed preferential co-occupancy with EBF1, and type 2 EBNA2 preferred RBPJ. These differences in hTF co-occupancy revealed possible mechanisms underlying type-specific gene expression of known EBNA2 human target genes: MYC (shared), CXCR7 (type 1 specific), and CD21 (type 2 specific). Both type 1 and 2 EBNA2 binding events were enriched at systemic lupus erythematosus (SLE) and multiple sclerosis (MS) risk loci, while primary biliary cholangitis (PBC) risk loci were specifically enriched for type 2 peaks. CONCLUSIONS: This study reveals extensive type-specific EBNA2 interactions with the human genome, possible differences in EBNA2 interaction partners, and a possible new role for type 2 EBNA2 in autoimmune disorders. Our results highlight the importance of considering EBV type in the control of human gene expression and disease-related investigations.

Epstein-Barr virus nuclear antigen 2 extensively rewires the human chromatin landscape at autoimmune risk loci.

The interplay between environmental and genetic factors plays a key role in the development of many autoimmune diseases. In particular, the Epstein-Barr virus (EBV) is an established contributor to multiple sclerosis, lupus, and other disorders. Previously, we showed that the EBV nuclear antigen 2 (EBNA2) transactivating protein occupies up to half of the risk loci for a set of seven autoimmune disorders. To further examine the mechanistic roles played by EBNA2 at these loci on a genome-wide scale, we globally examined gene expression, chromatin accessibility, chromatin looping, and EBNA2 binding in a B cell line that was (1) uninfected, (2) infected with a strain of EBV lacking EBNA2, or (3) infected with a strain that expresses EBNA2. We identified more than 400 EBNA2-dependent differentially expressed human genes and more than 5000 EBNA2 binding events in the human genome. ATAC-seq analysis revealed more than 2000 regions in the human genome with EBNA2-dependent chromatin accessibility, and HiChIP data revealed more than 1700 regions where EBNA2 altered chromatin looping interactions. Autoimmune genetic risk loci were highly enriched at the sites of these EBNA2-dependent chromatin-altering events. We present examples of autoimmune risk genotype-dependent EBNA2 events, nominating genetic risk mechanisms for autoimmune risk loci such as ZMIZ1 Taken together, our results reveal important interactions between host genetic variation and EBNA2-driven disease mechanisms. Further, our study highlights a critical role for EBNA2 in rewiring human gene regulatory programs through rearrangement of the chromatin landscape and nominates these interactions as components of genetic mechanisms that influence the risk of multiple autoimmune diseases.

Editorial Commentary: Tranexamic Acid Shown to Not Inhibit Healing Following Rotator Cuff Repair in Rats.

As use of tranexamic acid (TXA) to decrease operative bleeding has increased during various orthopaedic surgical procedures, there has been corresponding increased interest regarding additional potential benefits-and also potential risks-of its use. By lessening bleeding during and shortly after arthroscopic surgery, some potential benefits include less postoperative pain, less hemarthrosis, and subsequent decreased formation of scar adhesions, resulting in less permanent stiffness. However, use of this pharmacologic agent also raises the possibility of negative effects upon tissue healing. In a rat rotator cuff repair model, no lasting significant benefit was associated with TXA administration, including no long-term decreased adhesions or stiffness. On the other hand, no adverse effects regarding healing were noted with TXA.

UPLC-ESI-MS/MS Profiling of Secondary Metabolites from Methanol Extracts of In Vivo and In Vitro Tissues of Daucus capillifolius Gilli (A Comparative Study).

Daucus capillifolius Gilli is a rare annual wild herb grown in Libya. It belongs to the Apiaceae family, which is one of the largest flowering plant families. Plants of this family are outstanding sources of various secondary metabolites with various biological activities. A UPLC-ESI-MS/MS analysis of different extracts of in vivo and in vitro tissues of Daucus capillifolius together with the fruit extract of the cultivated plant in both ionization modes was carried out for the first time in the current study. Our results reveal the tentative identification of eighty-seven compounds in the tested extracts, including thirty-two phenolic acids and their derivatives; thirty-seven flavonoid glycosides and aglycones of apigenin, luteolin, diosmetin, myricetin and quercetin, containing glucose, rhamnose, pentose and/or glucuronic acid molecules; seven anthocyanins; six tannins; three acetylenic compounds; and three nitrogenous compounds. The tentative identification of the above compounds was based on the comparison of their retention times and ESI-MS/MS fragmentation patterns with those previously reported in the literature. For this Apiaceae plant, our results confirm the presence of a wide array of secondary metabolites with reported biological activities. This study is among the first ones to shed light on the phytoconstituents of this rare plant.

Reliability, validity and responsiveness of the Kurdish version of the questionnaire Disability of the Arm, Shoulder and Hand in patients with carpal tunnel syndrome.

INTRODUCTION: The Disabilities of Arm, Shoulder and Hand (DASH) questionnaire predicts the amount of the patient's inabilities and symptoms to evaluate the impacts of upper limb conditions in the patient's daily-life activities. This study aims to test the psychometric properties of DASH in Kurdish patients with carpal tunnel syndrome. MATERIALS AND METHODS: 93 patients with diagnosed carpal tunnel syndrome subjected to complete the self-report DASH-KU and patient rated wrist\hand evaluation PRWHEKU questionnaire during two consecutive assessments with a 24-hour interval before any intervention. RESULTS: DASH-KU questionnaire had excellent internal consistency (Cronbach's alpha = 0.99) and test-retest reliability (intra-class correlation coefficient =0.99). A strong correlation between the DASH-KU score and the PRWHE tool (r=0.792) demonstrated acceptable construct validity of DASH-KU. Bland-Altman plot showed good agreement between the two assessments of DASH-KU, and no floor (3%) nor ceiling effects (0%) were observed. Factor analysis showed that the DASH-KU scale had a high acceptable adequacy (adequacy index = 0.700) and a significant sphericity (p<0.001). The analysis showed a major factor that accounted for 40% of the observed variance with an eigenvalue of 13.14. In addition, five items model also explained 81.23% of the DASH-KU scale variance. However, the responsiveness of DASH-KU was suboptimum, which can be linked to the short 24-hour interval between measurements. CONCLUSION: The DASH-KU scale is a reliable, valid, and responsive instrument for assessing disabilities in patients with carpal tunnel syndrome.

Investigation of phytochemicals isolated from selected Saudi medicinal plants as natural inhibitors of SARS CoV-2 main protease: In vitro, molecular docking and simulation analysis.

The escalation of many coronavirus variants accompanied by the lack of an effective cure has motivated the hunt for effective antiviral medicines. In this regard, 18 Saudi Arabian medicinal plants were evaluated for SARS CoV-2 main protease (Mpro) inhibition activity. Among them, Terminalia brownii and Acacia asak alcoholic extracts exhibited significant Mpro inhibition, with inhibition rates of 95.3 % and 95.2 %, respectively, at a concentration of 100 µg/mL. Bioassay-guided phytochemical study for the most active n-butanol fraction of T. brownii led to identification of eleven compounds, including two phenolic acids (1, and 2), seven hydrolysable tannins (3-10), and one flavonoid (11) as well as four flavonoids from A. asak (12-15). The structures of the isolated compounds were established using various spectroscopic techniques and comparison with known compounds. To investigate the chemical interactions between the identified compounds and the target Mpro protein, molecular docking was performed using AutoDock 4.2. The findings identified compounds 4, 5, 10, and 14 as the most potential inhibitors of Mpro with binding energies of -9.3, -8.5, -8.1, and -7.8 kcal mol-1, respectively. In order to assess the stability of the protein-ligand complexes, molecular dynamics simulations were conducted for a duration of 100 ns, and various parameters such as RMSD, RMSF, Rg, and SASA were evaluated. All selected compounds 4, 5, 10, and 14 showed considerable Mpro inhibiting activity in vitro, with compound 4 being the most powerful with an IC50 value of 1.2 µg/mL. MM-GBSA free energy calculations also revealed compound 4 as the most powerful Mpro inhibitor. None of the compounds (4, 5, 10, and 14) display any significant cytotoxic activity against A549 and HUVEC cell lines.

The efficacy, safety, and outcomes of testosterone use among transgender men patients: A review of the literature.

INTRODUCTION: Gender dysphoria is the discrepancy between biological sex and gender identity. This can be debilitating for transgender populations, including transgender men (TM), individuals who were assigned female at birth but who identify as men, that can benefit from hormonal therapy with testosterone products to address gender dysphoria. METHODS: We aim to summarize the efficacy, safety profile, and outcomes of the different testosterone replacement treatment (TRT) in the TM population. A search of the published literature regarding the various FDA-approved TRT was performed in PubMed, Web of Science and Cochrane Library from 2007 to date. RESULTS: We complied two groups of TRT based on route of administration including the conventional testosterone therapies (intramuscular and subcutaneous injectables, and transdermal gels) and newer testosterone therapies (oral, buccal, and nasal gels). For the conventional testosterone therapies, we identified nine studies discussed conventional TRT in TM population including one randomized trial, four prospective studies, one retrospective study and three reviews. For newer testosterone therapies, we identified three studies discussed newer TRT in TM population including one prospective study and two reviews. Articles were then compiled and analyzed. Albeit majority of TRT data stemming from conventional TRT, there appear to be an overwhelmingly safety and efficacy profile in TM population translated with increased free testosterone levels comparable to male range, menses cessation, anxiety/depression decline and improved quality of life. CONCLUSION: Testosterone therapy can be impactful for TM population with improved safety, efficiency, quality of life and function. With the rise of the newer FDA-approved TRT, randomized studies are warranted to determine its safety and efficacity in this TM population.

A Systematic Review of Partner Satisfaction After Penile Prosthesis with Special Emphasis on LGBTQ + Populations.

PURPOSE OF REVIEW: Despite the current surgical advances and patients' satisfactions after penile prosthesis (PP) implantation, there has been paucity of data on reported partner satisfaction and their quality-of-life (QoL). Our objective was to summarize the current literature on partner satisfaction for both heterosexual and non-heterosexual populations, respectively. We specifically conducted a systematic review according to the Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards, and stratified studies into three tiers by methodological rigor. RECENT FINDINGS: After an initial search of 172 articles, 33 studies met the inclusion criteria for the final review: 30 for heterosexual partner satisfaction, and 3 for LGBTQ patient satisfaction were included due to lack of published literature on partner satisfaction for LGBTQ patients. For heterosexual partner satisfaction, 10 studies were classified as Tier 1, 11 studies were classified as Tier 2, and 9 studies were classified as Tier 3. From an initial search of 13 records, three studies consisting of 272 patients met the inclusion criteria for our LGBTQ review. Across all the tiers, studies noted satisfaction rates between 50 and 90% and improved satisfaction and sexual QoL metrics compared to pre-surgery rates. That said, partner satisfaction rates were also consistently lower than patient satisfaction rates. Although the range of evidence quality varies, the available literature suggests significant improvements in and relatively high rates of partner satisfaction after PP implantation. Given the diversity of study designs and widespread use of non-validated or non-specific questionnaires in the current literature, future research should focus on prospective studies and/or data collection using validated, PP-specific questionnaires.

Estimating 3D supraspinatus intramuscular fatty infiltration in older adults: a pilot study.

BACKGROUND: A recent report suggests that semi-quantitative two-dimensional Goutallier grade (2D-GG) correlates poorly with quantitative three-dimensional Dixon fat fraction (3D-Dixon-FF) on magnetic resonance imaging (MRI). PURPOSE: To determine whether the finding of poor correlation of supraspinatus 3D-Dixon-FF with 2D-GG is reproducible, and to determine the strength of the correlation of 3D-Dixon-FF with quantitative 2D Dixon fat fraction (2D-Dixon-FF). MATERIAL AND METHODS: Ten adults aged ≥60 years were recruited prospectively received shoulder MRI. 2D-Dixon-FF and 3D-Dixon-FF were measured on 6-point Dixon fat fraction maps. 2D-GG was rated on T1-weighted images. RESULTS: The mean age of participants was 70.7 ± 3.7 years. The mean 3D-Dixon-FF was 8.3% ± 5.7%; the mean 2D-Dixon-FF was 7.3% ± 4.4%; and the mean 2D-GG was 0.9 ± 0.7. There was a strong correlation for 3D-Dixon-FF with 2D-Dixon-FF (rho = 0.90; P < 0.001) and with 2D-GG (rho = 0.73; P = 0.017). Excellent inter-observer reliability was found for Dixon fat fraction (intraclass correlation coefficient = 0.946), which was good for Goutallier grade (weighted kappa = 0.634). CONCLUSION: Supraspinatus 3D-Dixon-FF had a strong correlation with 2D-Dixon-FF and 2D-GG in our study population.

International Knee Documentation Committee Radiographic Knee Joint Grading More Reliable Than Kellgren-Lawrence Grading and Other Grading Systems.

Kellgren-Lawrence grading appears to have become the de facto standard for reporting radiographic degeneration of knees, yet the much later-introduced and knee-specific International Knee Documentation Committee system has repeatedly been shown to have higher reliability. Although International Knee Documentation Committee radiographic grading does have limitations-especially in cases of severe gonarthrosis-it appears to be the most reliable current system suitable for the purposes of arthroscopic knee surgeons, and it was designed to encompass all 3 knee compartments. Posterior-anterior weight-bearing radiographs taken at approximately 45° of knee flexion have repeatedly been shown to be more sensitive for revealing tibiofemoral degeneration than standard anterior-posterior weight-bearing views at or near full extension.

WEIGHT LOSS AND BEYOND, ASSESSMENT OF QUALITY OF LIFE AFTER LAPAROSCOPIC SLEEVE GASTRECTOMY USING BAROS IN PATIENTS WITH OBESITY IN TURKEY.

Context: Sleeve gastrectomy is an effective method for management of obesity. The Bariatric Analysis and Reporting Outcome System (BAROS) is a comprehensive and standard system for the assessment of outcomes of weight loss surgery. It is consisted of weight loss, changes in obesity-related comorbidities and quality of life measurements. We investigated results of the sleeve gastrectomy based on the BAROS. Material and Methods: Outcomes of laparoscopic sleeve gastrectomy surgery was studied in 45 patients with obesity (11 male, 34 female), after 45 months in Turkey. Results: Total weight loss was 26.4±0.1% of body weight at 45 months. Weight regain was seen in 97.8% of the patients with an average 14.5 kg and 13.7% body mass index points. The surgery caused 76% decrease in incidence of obstructive sleep apnea, 73% decrease in type 2 diabetes, 63% decrease in hyperlipidemia and 62% decrease in hypertension. Significant improvement is observed in all quality-of-life parameters. The final score of the BAROS was 4.23±1.02. Conclusion: Based on BAROS, sleeve gastrectomy provides significant improvements in weight loss, incidence of medical comorbidities and quality of life after surgery. Future studies should address prevention of weight regain after the surgery.

Aesthetic Penile Augmentation Procedures: A Comprehensive and Current Perspective.

PURPOSE OF REVIEW: Some men experience small penis syndrome (SPS), a body dysmorphic disorder in which a patient believes their penis to be small even when it is clinically average. As cosmetic surgery becomes more widely accepted, management of SPS may present a challenge for urologists. We aim to provide an updated review of aesthetic penile augmentation procedures. RECENT FINDINGS: Augmentation procedures range from invasive to noninvasive. Surgical solutions include grafts and flaps, suspensory ligament release, and suprapubic lipectomy. Minimally invasive solutions include injections of fillers (hyaluronic acid, polylactic acid, and polymethyl methacrylate). Noninvasive solutions include external devices such as vacuum pumps and traction devices. In the current climate, aesthetic penile augmentation is becoming a desirable option for many patients but remains clinically controversial. Our review summarizes recent and relevant studies and demonstrates the need for further research and consensus on penile augmentation procedures.

Editorial Commentary: Subacromial Bursa May Possess Mesenchymal Progenitor Cells.

Subacromial bursal tissue biopsied during arthroscopic surgery for full-thickness rotator cuff tears appears to possess mesenchymal progenitor cells. Although attempting to harvest mesenchymal progenitor cells from the subacromial bursa for therapeutic purposes may currently be premature, the presence of these cells in bursal tissue does call into question the routine practice of subacromial bursectomy. To maximize the chances of healing after rotator cuff repair, perhaps it would be best to avoid excising non-diseased-appearing bursal tissue any more than what is absolutely necessary to facilitate visualization.

Improved osseointegration using porcine xenograft compared to demineralized bone matrix for the treatment of critical defects in a small animal model.

BACKGROUND: Autograft (AG) is the gold standard bone graft due to biocompatibility, osteoconductivity, osteogenicity, and osteoinductivity. Alternatives include allografts and xenografts (XG). METHODS: We investigated the osseointegration and biocompatibility of a decellularized porcine XG within a critical defect animal model. We hypothesized that the XG will result in superior osseointegration compared to demineralized bone matrix (DBM) and equivalent immune response to AG. Critical defects were created in rat femurs and treated with XG, XG plus bone morphogenetic protein (BMP)-2, DBM, or AG. Interleukin (IL)-2 and IFN-gamma levels (inflammatory markers) were measured from animal blood draws at 1 week and 1 month post-operatively. At 1 month, samples underwent micro-positron-emission tomography (microPET) scans following 18-NaF injection. At 16 weeks, femurs were retrieved and sent for micro-computerized tomography (microCT) scans for blinded grading of osseointegration or were processed for histologic analysis with tartrate resistant acid phosphatase (TRAP) and pentachrome. RESULTS: Enzyme linked immunosorbent assay testing demonstrated greater IL-2 levels in the XG vs. AG 1 week post-op; which normalized by 28 days post-op. MicroPET scans showed increased uptake within the AG compared to all groups. XG and XG + BMP-2 showed a trend toward increased uptake compared with DBM. MicroCT scans demonstrated increased osseointegration in XG and XG + BMP groups compared to DBM. Pentachrome staining demonstrated angiogenesis and endochondral bone formation. Furthermore, positive TRAP staining in samples from all groups indicated bone remodeling. CONCLUSIONS: These data suggest that decellularized and oxidized porcine XG is biocompatible and at least equivalent to DBM in the treatment of a critical defect in a rat femur model.

Virtual Radiology Readouts After the Coronavirus Disease (COVID-19) Pandemic.

Social distancing concerns arising from the coronavirus disease (COVID-19) pandemic have led to the emergence of virtual readouts in radiology training programs. Given the myriad benefits of virtual readouts, radiology departments should continue using virtual readouts in at least a hybrid format, even after social distancing restrictions become relaxed. This article highlights the challenges and opportunities associated with virtual readouts and provides guidance and strategies for their long-term implementation by training programs.

Self-Induced Trauma to the Genitalia: a Review of the Literature and Management Schemes.

PURPOSE OF REVIEW: Self-induced genital trauma is rare, and prompt and evidence-based early intervention can improve the urinary and sexual function of these complex patients. This review has surveyed current literature and treatment trends to evaluate the clinical approach to managing genital trauma. RECENT FINDINGS: A literature review was performed regarding self-induced genitalia trauma and trauma management between 2000 and 2019 using MEDLINE® database, the Cochrane Library® Central Search, Web of Science, and Google Scholar. In total, 42 articles were considered relevant and included in this review. Self-induced trauma can be appropriately managed with a multidisciplinary approach. Treatment goals are to preserve urinary, sexual, and reproductive function. Specific evaluation includes mechanism of injury, imaging, and determining the extent of injury and surgical repair, if indicated. Due to the rarity of these injuries and their emergent nature, much of the management is based on retrospective data. Further research is needed to improve long-term functional outcomes in trauma patients.

Editorial Commentary: Treatment Efficacy Found in Animal Studies May Not Translate to Humans.

Efficacy of low-intensity pulsed ultrasonography (LIPUS) has been demonstrated in several mammalian models of injury/repair of tendons, ligaments, and soft tissue-bone junctions. But human studies have not demonstrated benefit from such intervention. In addition to innate healing differences between humans and research animals, another reason for this outcome variance may be that animal investigations of LIPUS have so far focused on healing after acute intervention, whereas randomized clinical trials have only looked at treating chronic tendinopathy in symptomatic patients. On the basis of current animal data, potential clinical benefit of LIPUS is most likely to be demonstrated for addressing acute injuries or postoperative scenarios. Yet, a particularly important anatomic difference between humans and experimental land animals regarding ultrasonography is the presence of subcutaneous adipose in the former versus the lack thereof in the latter, especially in the extremities, because overlying adipose attenuates ultrasound waves directed at underlying injured, repaired, or reconstructed tissues.

New approach for selecting a suitable recycling collection program for recovered paper and pulp recyclables using AHP-TOPSIS techniques.

In the past decade, the use of multiple-criteria decision analysis technology has dramatically increased in solving complex real-world problems in solid waste management. Likewise, many municipalities have paid attention to finding feasible solutions for disposal and recycling of solid waste due to the increase in waste generation rates worldwide. Therefore, policy-makers must determine which recycling program to be implemented among various recycling program options. In this paper, a new approach to select a recycling program for recovered paper and pulp recyclables was proposed using analytic hierarchy process-Technique for Order Preference by Similarity to Ideal Solution (AHP-TOPSIS) techniques. A set of essential parameters of the decision-making system were identified, and a numerical case to illustrate the procedure was conducted. Our findings show very encouraging results to use a combined model between AHP and TOPSIS to select a suitable recycling program for different recovered recyclable materials.