Pseudomonas sp. OBA 2.4.1 under cadmium (CdCl2) stress and its influence on Cd stresses in pea (Pisum sativum L.) seedlings. It was revealed that strain OBA 2.4.1 is tolerant of up to 2 mM CdCl2, and seed treatment with the bacterium enhanced pea plant growth (length of seedlings) under 0.5 mM cadmium stress. This bacterial strain showed plant growth-promoting properties, including biofilm formation and siderophore activity. An important advantage of the studied strain OBA 2.4.1 is its ability to colonize the plant roots. Moreover, the inoculation with strain OBA 2.4.1 significantly reduced oxidative stress markers in pea seedlings under cadmium stress. These findings suggest that cadmium stress-tolerant strain OBA 2.4.1 could enhance pea plant growth by mitigating stress-caused damage, possibly providing a baseline and eco-friendly approach to address heavy metal stress for sustainable agriculture.Cadmium stress is a barrier to crop production, yield, quality, and sustainable agriculture. In the current study, we investigated the characteristics of bacterial strain  Heavy metals (HMs) adversely affect all processes occurring in plants and, in addition, are very toxic to the human body and can cause serious health problems for humans ,2. The ractivity . Cd2+ inhibition . Cd can hibition ,6. Sandaactivity .Pseudomonas sp. Belongs to PGPM [Pseudomonas sp. Grows very quickly [P. fluorescens, P. aureofaciens, P. chlororaphis, P. corrugate, P. putida, and others strains can be used as growth-stimulating agents, as well as protectors from the negative effects of HMs [To mitigate the problems associated with HMs contamination, there is an urgent need for alternative environmentally friendly technologies, such as the use of plant growth-promoting microorganisms/rhizobacteria (PGPM/PGPR), for future use. This includes various taxonomic groups that have a wide range of beneficial properties for plants. Rhizospheric bacteria  to PGPM ,9. These quickly ,9. Curres of HMs ,9,10. Bacillus sp. Strain ZC3-2-1 in Oryza sativa. Treatment with this strain significantly increased O. sativa biomass, but the content of Cd2+ and Zn2+ per unit of rice biomass did not change significantly. This fact proves that the Bacillus sp. ZC3-2-1 can increase the efficiency of the phytoremediation of soils contaminated with Cd-Zn, promoting phytoextraction and metal immobilization [Phytoremediation by PGPR is an effective environmental measure to increase the remediation of HMs-contaminated soils. There are works showing the positive effect of Cd-Zn-tolerant PGPR lization .Brassicaceae family are most often recommended as phytoremediation plants, since they have a relatively high resistance to HMs and exhibit the ability to accumulate them [Fabaceae family, which grow rapidly and gain a large biomass, but have a relatively low tolerance to HMs [Plants of the ate them ,13,14. He to HMs ,16. In ae to HMs . Such sye to HMs ,19,20,21Pseudomonas spp., four strains were selected: OBA 2.4.1, OBA 2.9, GOR 4.17, and STA 3, which were isolated from the rhizosphere of plants in the Southern Urals (Russia). The most effective strain of Pseudomonas sp. Was chosen for further research, particularly, the strain OBA 2.4.1, which increased the germination vigor of Medicago sativa L. seeds by 15% compared to the untreated control. In addition, among the studied strains of Pseudomonas sp., OBA 2.4.1 showed the greatest resistance to growth on media under Cd stress [Pseudomonas sp. OBA 2.4.1, analyzing its effect on Pisum sativum L. growth and tolerance under Cd stress. Previously, when studying the growth-promoting properties of d stress . TherefoPseudomonas sp. OBA 2.4.1 was isolated from the rhizosphere of the Oxytropis baschkiriensis by homogenizing soil samples in a sterile LB medium , with further subculture and growth at 28°C [The strain of  at 28°C . DNA fro at 28°C .To identify the isolated bacteria, the 16S rRNA gene was amplified using the universal primers fD1 5’- CCCGGGATCCAAGCTTAAGGAGGTGATCCAGCC-3’ and rD1 5’- CCGAATTCGTCGACAACAGAGTTTGATCCTGGCTCAG -3’ . For ampwww.ncbi.nlm.nih.gov accessed on 28 December 2022). Computational analysis of DNA sequence fragments was performed using the Clustal W multiple alignment method in the Megalign Lasergene program .Nucleotide sequences were determined on an Applied Biosystems 3500 automatic sequencer  using the Big Dye Terminator v. 3.1. The analysis was carried out using the Lasergene software package . Nucleotide sequences for comparative analysis were taken from the GenBank database  for 1 day.To obtain a fluorescently labeled strain of was used . Some of6 CFU/mL and 1 mL was transferred into the wells of the plate and incubated at 28°C and 50 rpm for 7 days. To determine the relative biofilm density, the gentian violet staining method  was used [Biofilms were examined on 24-well plastic plates (polystyrene) . Bacteria were grown for 24 h in Lauria–Bertani (LB) medium at 28°C and 140 rpm. The bacterial culture was diluted to 10was used . The optPseudomonas sp. OBA 2.4.1 to mobilize inorganic phosphorus was tested on plates with Muromtsev’s medium  containing insoluble phosphate. As a source of phosphorus, Ca3(PO4)2 was added to the medium at a concentration of 5 g/L [The determination of the ability of the of 5 g/L . A daily3 and 10 mM HCl. After that, 4 mL of a solution containing 7.3 mg of HDTMA was added to the chrome azurol solution. The resulting mixture was autoclaved and added to the sterile LB medium. The bacteria were grown on the medium for 2 days. A change in color to yellow, orange, or pink revealed the release of siderophores.CAS-blue agar was prepared as described by Schwyn (1986), with some modifications ,32. To p2O2) levels were determined according to [® Microcentrifuge 5415 R, Humburg, Germany, USA) at 15,000× g for 15 min. The concentration of H2O2 in the supernatant was spectrophotometrically  determined using xylenol orange in the presence of Fe2+ at 560 nm. The H2O2 was expressed as µmoL g–1 FW.Hydrogen peroxide  TBA in 20% TCA. The mixture was incubated in boiling water for 30 min, and the reaction was stopped by placing the reaction tubes in an ice bath. Then, the samples were centrifuged at 10,000× g for 5 min. Absorbance was spectrophotometrically  measured at 532 nm. The amount of MDA–TBA complex (red pigment) was calculated from the extinction coefficient 155 mM−1 cm −1. The MDA was expressed as nmoL g–1 FW.For the measurement of lipid peroxidation in leaves, the thiobarbituric acid (TBA) test, which determines MDA as an end product of lipid peroxidation , was usePisum sativum L., Kelvedonskoye miracle variety) were sterilized in 70% ethyl alcohol for 1 min and 10% sodium hypochlorite solution for 20 min [Pseudomonas sp. OBA 2.4.1 (107 CFU/mL) for 30 min and germinated on filter paper with sterile water (control) and various concentrations of CdCl2  (stress) at 24 ± 1°C in the dark for 7 days. Seven-day-old seedlings were taken to assess their shoot length. For the analysis, 50 seedlings were used in each variant in three independent biological replicates.Pea seeds . Statistically significant differences between the mean values were evaluated using analysis of variance (ANOVA), followed by the Tukey test (p < 0.05).http://www.ncbi.nlm.nih.gov/genbank accessed on 28 December 2022) under the number OK039351 and in the rpoD gene under the number OM641958. When comparing fragments of the 16S rRNA and rpoD gene sequences with typical strains, it was found that Pseudomonas sp. OBA 2.4.1 is closest in homology to Pseudomonas fluorescens. This strain is described in detail in a previous study [The sequenced 16S rRNA sequence was deposited in GenBank  by 1.5 times and 1.6 times, respectively. At the same time, the treatment itself with Pseudomonas sp. OBA 2.4.1 did not affect the state of the membrane structures under normal conditions.This result is accompanied by the same level of MDA accumulation , but trePseudomonas sp. OBA 2.4.1 transformed with the pJNTurboRFP vector. The bacteria have not lost their resistance to Cd. The fluorescent label made it possible to visualize bacterial cells on the surface of the root hairs of germinated pea seedlings. Microscopy showed the formation of bacterial clusters and microcolonies of Pseudomonas sp. OBA 2.4.1 on the roots of peas.P. aeruginosa bacteria formed a biofilm, they became more resistant to HMs ions  compared to single bacteria, since polymer compounds bind metal ions, preventing them from entering the biofilm [Pseudomonas sp. OBA 2.4.1 also has the ability to form a biofilm, which characterizes it as a PGPM with good competitiveness. Another indicator of PGPM quality was the discovery of siderophore activity  stimulated an increase in plant height, which may be associated with their certain resistance to Cd, but high levels of Cd2+ inhibited the height growth of plants of the sorghum genus [2+ under growing conditions can stimulate plant growth to a certain extent, while higher concentrations suppressed their growth [When growing seeds under cadmium stress at low concentrations of Cd , an improvement in the growth of seedlings was observed. Further, an increase in the concentration of Cd led to the inhibition of seedlings growth. A similar effect is observed in many studies regarding cadmium stress. For example, Jalil et al. (1994) found that a low concentration of Cdarieties . Yang ete growth . It is aum genus . Thus, ir growth .Medicago sativa L. plants treated with PGPR and grown in the presence of Cu, Pb, and Zn increased shoot length by 22–77% and shoot biomass by up to 220% compared to untreated plants [Atriplex halimus and Arthrocnemum macrostachyum plants growing in the presence of HM showed an improvement in their morphometric parameters compared to the untreated controls. This may be due to the fact that microorganisms improve plant nutrition by dissolving phosphates, iron, and nitrogen fixation; in addition, they can stimulate plant growth by secreting auxins [Many studies show that PGPM treatment has a positive effect on plants, even in the presence of HMs in the medium. For example, alfalfa d plants ,45. Treag auxins ,49,50,51Thus, plant resistance to the toxic effect of Cd may be due to more efficient root growth due to the positive effect of substances released by microorganisms and a decrease in the concentration and accumulation of HMs in the plant root system. The predominant accumulation of Cd in the roots compared to its accumulation in the aboveground plant organs is determined by the barrier functions of the plant root system in relation to toxic HMs . In our Pseudomonas sp. OBA 2.4.1, isolated from the rhizosphere of the Oxytropis baschkiriensis, had a growth-promoting and protective effect on pea plants under Cd stress. Treatment with OBA 2.4.1 resulted in a 2.6-fold increase in seedling length compared to the untreated plants. The bacterium exhibits PGP properties, including biofilm formation and siderophore production. Moreover, the strain OBA 2.4.1 contributed to the reduction of oxidative stress caused by Cd. The level of hydrogen peroxide and MDA is significantly lower than in untreated stressed plants. In addition, bacteria are able to colonize the roots of pea plants. This ability of bacteria also positively affects the growth and development of plants under stress. The evaluation of the current study suggests that the strain Pseudomonas sp. OBA 2.4.1, can potentially be used as a promising alternative and an environmentally friendly approach to facilitating pea growth and stress tolerance under cadmium stress. However, further field experiments are required to evaluate its full potential for mitigating heavy metals-caused stress in plants.The present study showed that seed inoculation with


Studies reporting vaccine effectiveness against COVID-19 outcomes concentrate mainly on estimates of one single type of vaccine and variant, seldom considering waning effects. We aimed to estimate the effectiveness of the overall COVID-19 vaccination programme implemented in the Apulia region of Italy at preventing SARS-CoV-2 infections, COVID-19-related hospital admissions and deaths during alpha and delta variant dominant periods. We conducted a retrospective cohort study using electronic health records of persons 16 years and older resident in the Apulia region, assessing the effectiveness of the combined use of BNT162b2, mRNA-1273, ChAdOx1-S and Ad26.COV2.S vaccines against confirmed COVID-19 infections, hospitalisations and deaths, for fully and partially vaccinated persons as well as by time since vaccination and variants. Cox regression models yielding hazard ratios were used to calculate the overall vaccination programme effectiveness. From 1 January to 1 December 2021, we included 3,530,967 eligible persons in the cohort, of whom 2,770,299 were fully vaccinated and 158,313 were COVID-19 positive at the end of the study period. The effectiveness of the programme over the entire study period for fully vaccinated persons against COVID-19 infection, hospitalisation and death were 87.69% (CI95% 87.73–88.18), 94.08% (93.58–94.54) and 95.95% (CI95% 95.26–96.54), respectively. The effectiveness against COVID-19 infection of fully vaccinated subjects during the alpha and delta period was respectively 88.20% (CI95% 87.60–99.78) and 59.31% (CI95% 57.91–60.67), against hospitalisation 93.89% (CI95% 92.67–94.90) and 88.32% (CI95% 86.50–89.90) and against death 93.83% (CI95% 91.65–95.45) and 85.91 (CI95% 79.98–90.09). The waning effects of the programme regarding COVID-19 infection during the delta period were stronger than for alpha, with 75.85% (CI95% 74.38–77.24) effectiveness after 1–2 months and 8.35% (CI95% 3.45–13.01) after 5–6 months after full vaccination. The effectiveness against hospitalisation and death during the delta period waned rapidly and at 7–8-months after the full vaccination respectively decreased to 27.67% (CI95% 7.48–43.45) and 48.47 (CI95% 53.97–34.82). Our study suggests that the COVID-19 vaccination program in Apulia was strongly protective against COVID-19 infection, hospitalisation, and death due to alpha as well as delta variants, although its effectiveness is reduced over time. Within one year, five COVID-19 vaccine candidates have been approved by the European Medicines Agency2 as well as the Italian medicines agency (AIFA)3, with several more in the development pipeline. The approved vaccines as originally shown in trials suggested to be highly efficacious against moderate-to-severe disease among adults, with an efficacy of 95% for the BNT162b2 (Pfizer–BioNTech) vaccine4, an efficacy of 94% for the mRNA-1273 (Moderna) vaccine5, an efficacy of 70% for the ChAdOx1-S (Astra Zeneca) vaccine6, an efficacy of 72% for the Ad26.COV2.S (Johnson & Johnson–Janssen) vaccine7, and an efficacy of 90% for the NVX-CoV2373 (Novavax) vaccine8. However, the end points of those trials were evaluated at a relatively short follow-up of 14 to 28 days after series completion, with notable limitations of sample size, restrictive inclusion criteria and during a period when the circulating strains were less transmissible than the currently circulating variants of SARS-CoV-29.As of January 10, 2022, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has resulted in more than 308 million cases and more than 5,5 million deaths worldwide12. Nevertheless, although initially the effectiveness was found to be closely reflecting the results of efficacy trials, extended trial follow-up and an increasing number of real-world effectiveness studies have begun to document declines in vaccination effectiveness (VE) for some outcomes and in some populations during 202113. An important reason for this reduction is suggested to be due to the emergence of new strains of the original COVID-19 virus found in 201915. After the initial “wild type” variant , four main variants of concerns have been identified to date 9. Although data suggests that reduced sensitivity of variants to neutralising antibodies occurs16, substantial levels remain17. However, the main driver for the reduced effectiveness of vaccine programmes is related to the waning of vaccine immunity19.Since the introduction of the approved vaccines, various real-world studies have reported on the effectiveness of partial and full vaccination against COVID-19 related infection, hospitalisation, and deathUnderstanding the impact of these factors, namely the emergence of variants and waning immunity, in relation to the success of vaccination programmes is of paramount importance. Post authorization analyses meet the urgent need to evaluate the magnitude and sources of changes in the effectiveness of COVID-19 vaccines implemented through different vaccination strategies and across diverse populations with a wide range of coexisting conditions. Ultimately with the aim to develop vaccine recommendations and inform public health policy. In this study, we assessed the effectiveness of the COVID-19 vaccination programme implemented in the Apulia region of Italy in preventing SARS-CoV-2 infections, COVID-19-related hospital admissions and deaths. It has been almost two years since mass vaccination campaigns using newly approved vaccines against SARS-CoV-2 started in the Apulia region. The availability of vaccination data from nearly four million people over almost two years of vaccination programme allows a comprehensive narrative about its effects on COVID-19 related outcomes.We conducted a retrospective cohort study by analysing electronic health records from the Apulia region health-care information system. We assessed the effectiveness of the combined use of four vaccines  in the immunization programme against SARS-CoV-2 infections, COVID-19-related hospital admissions and deaths. We also performed the analysis separately for mRNA vaccines (BNT162b2 and mRNA-1273) and viral vector vaccines (ChAdOx1-S and Ad26.COV2.S). The study period ran from 1 January to 1 December 2021.20, the index was based on demographic (age and sex) and clinical (29 conditions and diseases) predictors of the COVID-19 severity. According to the index, our study population was categorized into 3 groups: not fragile/at low level of fragility , fragile  and very fragile . We considered as vaccine doses administered those recorded in the regional Immunization Information System. If a record of a second dose was found without a record reporting the first dose, we considered the registered dose to be the first. The study followed the guidelines of the STROBE . The protocol for this study was reviewed by the Apulia region Health Authority. As this study constituted public health surveillance, ethical approval from institutional review board was not required. All data were provided and analysed anonymously.A total of 4.09 million inhabitants were registered in the Apulia region as of December 1, 2021. In the study cohort, we included all residents aged ≥ 16 years. We excluded from the analysis individuals who had tested positive for SARS-CoV-2 infection before January 1, 2021. Moreover, people who died for other causes than COVID-19 or moved out of the region during the study period ceased to be in the study cohort at the date of death or at the date of moving. Electronic health records integrated clinical data including diagnostic, laboratory, hospitalisation, and vaccination history information across all settings of care. A comorbidity assessment was associated with the study participants through a medical vulnerability index taking values from 1 to 100. As extensively described elsewhere21.The Apulia region is located in southeast Italy and consists of six administrative divisions, named provinces. In Italy, the Ministry of Health led vaccination programme planning. The regional authorities are in charge of organizing and implementing the new vaccination strategies at the local level. The COVID-19 vaccination programme in Italy began on December 27, 2020, and it was at the start targeted at health care workers, residents in nursing homes, and medical risk groups. Gradually, descending by 10-year steps and extending to other vulnerable groups, over the first six months of 2021 eventually all population over 16 years were called to receive full anti-COVID-19 immunization. The BNT162b2 vaccine was available since 27 December 2020, however initially the number of doses were extremely limited. The mRNA-1273 and ChAdOx1-S vaccines were subsequently delivered during the next months. In the case of the ChAdOx1-S vaccine, it was administered mainly to some professional risk groups, such as security forces workers and school staff. By April 2021 small numbers of the Ad26.COV2.S vaccines started to be administered in the Apulia region. In March and April ChAdOx1-S and Ad26.COV2.S were scrutinised for adverse effects and temporarily suspended but their administration occurred mostly until mid-August. With the worldwide production of vaccines substantially increasing, the majority of the vaccines administered in the Apulia region since May were the BNT162b2 vaccineFull vaccination status was defined as having received a single dose of Ad26.COV2.S or two doses of BNT162b2 or mRNA-1273 or ChAdOx1-S or a combination of them from seven days after vaccination. Individuals were defined partially vaccinated if they received only one dose of BNT162b2 or mRNA-1273 or ChAdOx1-S from 7 days or more or if they received two doses of COVID-19 vaccine for less than 7 days. Individuals were considered unvaccinated until seven days after administering of their first dose of vaccine, or until censoring at disenrollment or death. A person was classified as exposed if one or two doses of vaccine were administered between January 1 and December 1 2021, with maximum follow-up time censored until December 1, 2021. Persons that received a third/booster dose were censored from the date of that dose.22. Since in the Apulia region no population-wide information on sequencing results was available, we used the evidence above-mentioned to determine the variant for SARS-CoV-2 causing the infection. Hence, all COVID-19 cases between January and June 2021 were considered caused by alpha variant, while from July onwards all cases were considered caused by delta variant. Hospital admissions were included if COVID-19 was the main cause for the hospitalisation. A COVID-19 related death was defined as a death with a positive SARS-CoV-2 test that was conducted in the 28 days prior to death.Outcomes comprised SARS-CoV-2 infection, defined as a positive real-time PCR test result or as a positive third-generation antigen test result obtained from any public or private facility in the Apulia region, COVID-19 related hospitalisation and death. Every health care provider in the Apulia region is obligated to submit SARS-CoV-2 infection related results to the regional health authorities. According to surveillance data of Apulia region, nearly 90% of cases between January 1 and July 1 2021 were caused by the alpha variant. In June, 20% of SARS-CoV-2 sequenced resulted to be delta variant increasing up to the 80% in July, while as of December 1, over the 90% of cases were caused by deltaDescriptive statistics reported demographic variables and a medical vulnerability index. We presented the cumulative number of fully and partially vaccinated persons over time in the Apulia region by sex, age category , province and fragility index , as well as the number of fully vaccinated persons per type of vaccine and by age at the end of the study period. Subsequently, the number of infections by vaccination status was presented. Person-time for unvaccinated persons was comprised of follow-up time for those vaccinated until censoring, partial or full vaccination, in addition to the time contributed by those never vaccinated.In the primary analysis we compared infection, hospitalisation, and death rates over the whole study period between unvaccinated and fully vaccinated as well as between unvaccinated and partially vaccinated. We performed this analysis by the whole cohort as well as by age category . Fully vaccinated persons were further analysed bi-monthly by time since vaccination  and by SARS-CoV-2 variant . The calculation of follow-up time and COVID-19 outcomes were computed from seven days after the final vaccination dose. The follow-up time and COVID-19 outcomes of the unvaccinated group were kept constant to the full study period. Additionally, analyses were performed on time since infection by different COVID-19 virus variants. Time since vaccination for alpha cases was never more than 5.5 months (mid-January the first person was fully vaccinated), and therefore estimates were reported on a one-monthly basis. We allowed follow-up time for vaccinated with a COVID-19 event in the delta period to start before 1 July, whereas for the unvaccinated group follow-up time started from the delta period. Additionally to these analyses including all administered vaccine products, we reported the undifferentiated analyses also separately for mRNA vaccines (BNT162b2 and mRNA-1273) and viral vector vaccines (Ad26.COV2.S and ChAdOx1-S).For our analyses we used Cox hazard regression models yielding hazard ratios (HRs) with 95% confidence intervals (CI95%). For all models, effectiveness of the combined use of four vaccines and mRNA/viral vector vaccines was computed as 1-HR, multiplied by 100. We added covariates to the unadjusted models to derive estimates in adjusted models comprising of calendar week , sex, age (per five years), province, week of infection (account for varying infection rates over time) and a fragility index.We used RStudio  for all analyses, including the survminer package for the analysis of survival data.As this study was conducted within the public health surveillance programme established by the Ministry of Health, ethical approval was not required. All procedures contributing to this work complied with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. Moreover, according to the Italian regulation , this retrospective epidemiological study had only to be notified to the Regional Public Health Authority for the nature of the study itself. Informed consent was not obtained from participants because surveillance data and molecular and antigenic testing were retrieved and analysed anonymously.From 1 January to 1 December 2021, 3,530,967 individuals were included in the study cohort. The 51.72% of participants were female and 48.27% were male. The median age was 51.6 years old. Following the personal medical vulnerability index, 91.20% of the study participants were not fragile, 7.94% were fragile and 0.86% were very fragile.At the end of the study period 78.46% were fully vaccinated and 5.18% were partially vaccinated. A total of 1,997,940 72.12%) individuals received 2 doses of BNT162b2, 373,713 (13.49%) 2 doses of mRNA-1273, 310,551 (11.21%) 2 doses of ChAdOx1-S, and 57,068 (2.06%) 1 dose of Ad26.COV2.S  were admitted to hospital and 3658 (2.31%) deceased  for individuals who were fully vaccinated and 68.17% (CI95% 67.40–69.93) for partially vaccinated persons  for individuals between 16 and 44 years, 88.28% (CI95% 87.92–88.63) between 45 and 64 years, and 87.62% (CI95% 87.18–88.05) for those older than 64 years. The results were homogeneous in the three age groups also for the effectiveness against hospitalisation  and death   during the 1–2 months after full vaccination to 88.14% (CI95% 87.76–88.52) after 3–4 months and to 61.91% (CI95% 57.47–65.89) after 9–10 months. Similar trends were observed for the various age categories  for fully vaccinated and 56.69% (CI95% 55.50–57.86) for partially vaccinated individuals. The effectiveness against hospitalisation was 93.89% (CI95% 92.67–94.90) for fully and 59.57% (CI95% 55.88–62.94) for partially vaccinated persons. The effectiveness against death was 93.83% (CI95% 61.65–95.45) and 61.12% (CI95% 25.12–88.18) for fully and partially vaccinated individuals, respectively  for fully vaccinated and 30.94% (CI95% 26.62–35.01) for partially vaccinated persons. The effectiveness against hospitalisation was 88.32% (CI95% 86.50–89.90) and 85.91% (CI95% 79.98–90.09) against death  after one month after being fully vaccinated and 83.19% (CI95%77.09–87.54) after > 4 months while the effectiveness against infection with the delta variant was reduced from 75.85% (CI95% 74.38–77.24) during 1–2 months after full vaccination to 8.35% (CI95% 3.45–13.01) after 5–6 months and to − 55.99% (CI95% − 67.36 to − 45.39) after 7–8 months , hospitalisation  and death . Moreover, the protective effect of full vaccination wanes gradually over time with the delta variant showing a more rapid decline.25. Minimal variations were observed among the different age groups. However, in line with findings elsewhere in Europe26, for those only partially vaccinated the effectiveness was lower, respectively with 68.17%, 68.42% and 72.92% with the 65 + year age group being considerably less protected  against infection only ten months after full vaccination, with 82.06% (CI95% 81.42–82.67) effectiveness after 5–6 months   for the alpha dominant period and 59.31% (CI95% 57.91–60.67) for the delta dominant period (July-November)  and in those aged ≥ 60 years  at 27–30 weeks after the second dose31.Our study covered a period in which at first the alpha variant was dominant followed in July by the delta variant being dominant in Italyer) Fig. a. Theref32: effectiveness against hospitalisation for alpha and delta dominance was respectively 97% and 84% for BNT162b2 and 97% and 71% for ChAdOx1. Thus, the effectiveness against the delta variant is reduced considerably for infection, but to a lesser degree for COVID-19 attributed hospitalisation and death.However, in our analysis, for hospitalisation due to COVID-19 over the study period the differences in effectiveness between alpha and delta remain modest (93.89% and 88.32%) consistent with a major study conducted in the UK13. Moreover, we found that even the effectiveness against hospitalisation and death due to delta 1–2 months after full vaccination is reduced—the protection rapidly wanes indicating that after 7–8 month the effectiveness is respectively 27.67% and 48.47%.Although the gradual waning of vaccine effectiveness over time against various outcomes in the alpha dominant period is relatively well documented, this is not the case for the delta variant. We found that not only the effectiveness against infection with delta is much lower than with alpha, also the effectiveness wanes at a much higher pace with 75.85% effectiveness after 1–2 months and 8.35% after 5–6 months. In one study in the US the effectiveness of BNT162b2 against infection with delta was reduced to 61% after 3–4 months which in our study was 54.29%33. Although the delta variant phase is now over, these results may be of interest to public health authorities, should a delta-like variant emerge.Our study suggests that the estimates of effectiveness of an actual vaccine programme with multiple vaccines remains of high importance in controlling the COVID-19 pandemic. Full vaccination provides high levels of protection against hospitalisation and death for both variants of COVID-19. However, although the effectiveness against hospitalisation and death due to delta 1–2 months after full vaccination is reduced—the protection rapidly wanes indicating that after 7–8 months the effectiveness is respectively 27.67% and 48.47%. A systematic review of immunological studies on the waning effect after full vaccination with various vaccines find rapidly declining neutralising antibody titres patterns that are concordant with these findings34 also deployed in various other studies35. Moreover, the distribution of fully vaccinated persons by type of vaccine in our study closely resemble those of major vaccine programmes in Europe as well the distribution of vaccines of all EU countries combined36.Our study has several limitations to take into account. We estimated the effectiveness of the entire vaccination programme on COVID-19 outcomes, and we compared the undifferentiated results to those from results of analysis of effectiveness of mRNA and viral vector vaccines. Even though we do not report the vaccine effectiveness by brand, this approach does allow us to estimate a realistic real-world effect of the COVID-19 Vaccination programme, representative of those around Europe. This real-world example of an assessment of a combined vaccine effectiveness programme follows a field evaluation approach22. On basis of these data, we approximated the alpha (January–June) and delta (July–November) dominant period accepting that some of the COVID-19 cases in those periods were due to another variant. With the relatively more transmissible but less severe Omicron variant37 becoming dominant rapidly from December 2021 onwards22 as well as the booster dose becoming the rule rather than the exception, we attempted to reduce biases potentially arising from these dynamics by limiting the analysis until December 1.Further, no individual data on virus strain was available for COVID-19 cases in the Apulia region for our analysis of the effectiveness against COVID-19 variants. To estimate the periods in which the alpha and delta variant were dominant, we consequently relied on a sample of sequenced results38.Additionally, unlike randomised trials, our study design does not account for bias arising from variation in the study population. We considered for several factors that might have been unevenly distributed among the study population over time, including the calendar week  and week of infection (accounting for incidence of disease). Moreover, we were able to adjust for some critical personal factors that could potentially bias the effectiveness, including sex, age, residency, and fragility. However, the effectiveness estimates might be confounded due to skewed test-seeking behaviour among vaccinated and unvaccinated people and population groups with different socio-economic status31.Moreover, including all individuals aged 65 + years as a single group might have masked differences in effectiveness between the younger and the oldest groups, among whom the risk of hospitalization and death was reported to be much higherFinally, the interpretation of the results of the study compared to other vaccine programmes need to be done with some degree of precaution since every population in Europe has its own unique features making extrapolation a somewhat complicated.40. Booster doses of vaccines primarily to vulnerable people and to those 65 years and older is therefore of crucial importance in order to maintain adequate protection against hospitalisation and death by COVID-19 variants.In conclusion, the vaccine programme in the Apulia region has showed to be very effective in averting deaths and hospitalisation against the alpha as well as delta variant, although its effectiveness is reduced for the latter. The waning of the effect after full vaccination against COVID-19 is evident, suggesting that after 4–6 months an extra dose is required. Encouragingly, recent studies on the effectiveness of a third dose have found that such boosters with BNT162b2 as well as with ChAdOx1 elicit even higher levels of serological responses than after two dosesAdditional studies to the effectiveness over time of the available vaccines against new variants such as Omicron are essential to further inform public health decision making.Supplementary Tables.


Litsea cubeba 0.5 and 1.0% concentration in rapeseed oil combined with aerobic and vacuum packaging. The meat was evaluated for microbiological quality (counts and microbiota identification) for 20 days under refrigerated storage. Our result show that Litsea cubeba essential oil is an effective natural agent against deer meat spoilage bacteria.Consumers are increasingly turning to healthier and less environmentally harmful diet alternatives. Game is an ideal food from this point of view because it represents meat with a high protein content, low fat content, a favourable composition of fatty acids and minerals. Various types of packaging are often used to extend the shelf life of meats. Packaging can be combined with natural antimicrobials, such as various plant extracts and essential oils, for better effectiveness. Little is known about the microbial quality and preservation of deer meat. In the present study, deer meat was treated with essential oil from Litsea cubeba (dissolved in rapeseed oil at concentrations 0.5 and 1%), in combination with vacuum packaging during 20 days of storage of meat at 4 °C. Total viable counts (TVC), coliforms bacteria (CB), lactic acid bacteria (LAB) and Pseudomonas spp. were analysed at day 0, 1, 5, 10, 15 and 20. MALDI-TOF MS Biotyper technology was applied to identify microorganisms isolated from meat. The highest number of TVC at the end of the experiment was 5.50 log CFU/g in the aerobically packaged control group and the lowest number of TVC was 5.17 log CFU/g in the samples treated with 1.0% Litsea cubeba EO. CB were not detected in the samples treated with 1.0% Litsea cubeba EO during the entire storage period. Bacteria of the genus Pseudomonas were detected only in the aerobically and vacuum packaged control group. The highest number of LAB was 2.06 log CFU/g in the aerobic control group, and the lowest number of LAB was 2.01 log CFU/g in the samples treated with 1.0% Litsea cubeba EO on day 20. The most frequently isolated bacteria from deer meat were Pseudomonas ludensis, Pseudomonas corrugata, Pseudomonas fragi, Bacillus cereus, Staphylococcus epidermidis and Sphingomonas leidyi.The present study aimed to evaluate deer meat microbiological quality when treated with essential oil (EO) from  Pseudomonas spp., Lactobacillus spp. and Enterobacteriaceae. Pseudomonas spp. is dominant in spoiled meat. Facultative anaerobic bacteria, genus Lactobacillus spp. dominate in vacuum-packaged meat [Pseudomonas have been identified as responsible for the deterioration of fresh meat stored under aerobic conditions. They are among the fastest growing organisms in aerobic conditions at low temperatures [The quality of wild animal meat is influenced by various external and internal factors. The external ones include climatic and seasonal conditions, which affect pastures, as well as the environment in which the animals live, the internal factors are mainly age, sex, physical and sexual activity of the animals . Meat isged meat . The spoged meat . Bacterieratures . Coliforeratures . Little eratures . MALDI-Teratures  and woulLitsea cubeba (LC) or Cuban laurel is a small dioecious deciduous tree or shrub that occurs wild in tropical and subtropical regions, especially in Asia, Malaysia, Indonesia, China, and Taiwan [Litsea cubeba essential oils are characterised by antibacterial, antiparasitic, antifungal, antioxidant, antiseptic, antiviral and insecticidal effects and have potential uses for different industries [Litsea cubeba plant contain essential oil (EO). EO content in the fruit is in the range of 0.3–5% [Litsea cubeba has a light-yellow colour, a fresh sweet-fruity lemon scent. It is used in the chemical, cosmetic and medical industries, and, it is also added to food and tobacco products. The main chemical component of the EO from Litsea cubeba is citral, which is a mixture of stereoisomers geranial and neral. Other ingredients include limonene, methylheptane and pinene to linalool. However, the chemical composition is variable, depending on the cultivation place and climate [The identification of the microbial populations in meat would be a first step towards defining strategies for meat preservation. The evaluation of meat storage conditions, such as packaging conditions combined with the use of natural antimicrobial substances, would be another contribution to meat safety. In this sense, some plant extracts, mainly essential oils, have antimicrobial properties that can be potentially suitable for meat preservation. d Taiwan . Plants dustries ,15. Essedustries , howeverdustries . All parf 0.3–5% ,18. EO f climate . The int climate . At pres climate , howeverLitsea cubeba.The present study was aimed to evaluate the microbiological quality of vacuum packaged deer meat stored at 4 °C for 20 days and treated with 0.5 and 1.0% essential oil from musculus semimembranosus) were used in this experiment. The meat was bought from an authorised store; the meat sample was obtained from a young male deer living in the wild, according to label information estimated age was 2 years, and it was bought 48 h after the catch. The animal was shot by a bullet in the neck area, in the village of Devičany , Nitra region, in Slovakia. The meat samples were transported under hygienic conditions in a cleaned refrigerator to the microbiological laboratory, where they were stored at temperature 4 °C until the analysis was performed. Samples were transported from the authorised store to the laboratory within 30 min. Meat was diced, samples weighing 5 g were treated with solutions of 0.5 and 1.0% Litsea cubeba fruit essential oil (LCEO)  dissolved in rapeseed oil and vacuum packaged using a vacuum packer . Food grade rapeseed oil was purchased from an authorised store. The EO was previously characterised by Borotová et al. [Control aerobically packaged group: Meat samples were packed in polyethylene bags under aerobic conditions and stored at 4 °C;Control group with vacuum packaging: Samples of fresh meat were packed in polyethylene bags and stored under anaerobic conditions at 4 °C;Control group with rapeseed oil: Meat was treated with rapeseed oil, packaged in polyethylene bags, and stored under anaerobic conditions at 4 °C;Litsea cubeba essential oil: Meat samples were soaked in a solution of rapeseed oil containing 0.5% Litsea cubeba essential oil, then packed and vacuum sealed in polyethylene bags, and further stored under anaerobic conditions at 4 °C;Vacuum-packaged with 0.5% Litsea cubeba essential oil: Meat samples were soaked in a solution of rapeseed oil containing 1.0% Litsea cubeba essential oil, packed and vacuum sealed in polyethylene bags, and stored under anaerobic conditions at 4 °C.Vacuum-packaged treated with 1.0% Thigh muscle samples of deer meat  incubated at 35 °C for 48 h. Coliforms bacteria were determined in Violet Red Bile Lactose Agar  incubated at 37 °C for 24 to 48 h. Total viable counts were determined in Plate Count Agar  incubated at 30 °C for 48–72 h.Microbiological analyses were performed on days 0, 1st, 5th, 10th, 15th and 20th of storage at 4 °C. Five gram samples were diluted with 45 mL of 0.1% sterile saline solution. The samples were homogenised in a shaker  for 30 min. The following microbial populations were evaluated: Lactic acid bacteria (LAB) were determined in media De Man, Rogosa and Sharpe agar  incubated with 5% of COMALDI-TOF (matrix-assisted laser desorption/ionisation time of flight) MS Biotyper  was used to identify microorganisms isolated from deer meat samples based on the comparison of the obtained patters with reference libraries.A stock solution that served as an organic reagent was prepared including: 50% of acetonitrile, 47.5% of water and 2.5% of trifluoroacetic acid . Two hundred and fifty microliter of the organic solvent was prepared and mixed in an Eppendorf flask with “HCCA matrix portioned”. All chemicals for matrix preparation were purchased from Lambda Life .g for 2 min . After discarding the supernatant, the precipitate was allowed to dry at 20 °C. Then 30 μL of 70% formic acid and 30 μL of acetonitrile were added to the pellet. Subsequently, the mixture was centrifuged at 10,000× g for 2 min. The supernatant of 1 μL was pipetted onto a MALDI plate, left to dry, and immediately, 1 μL of MALDI matrix solution was pipetted onto the plate. After drying, the samples were prepared for identification of microorganisms in a MALDI-TOF mass spectrometer . Mass spectra were automatically generated using the microflex LT MALDI-TOF mass spectrometer  operated in the linear positive mode within a mass range of 2000–20,000 Da. The instrument was calibrated using the Bruker bacterial test standard. Results of mass spectra were processed with the MALDI Biotyper 3.0 software . The identification criteria used were a score of 2.300 to 3.000 indicated highly probable identification on species level; a score of 2.000 to 2.299 secure genus identification with probable species identification; a score of 1.700 to 1.999 probable identification to the genus level; <1.700 was considered as unreliable identification.Samples were prepared as previously described . BrieflyAll measurements and analyses were carried out in triplicate. Statistical analysis and means comparison were run using software SPSS 26.0 . ANOVA test was used to test the differences. Tukey HSD test was used for means comparison (95% confidence level).Litsea cubeba Pers. Fruit. was composed of 39.39% geranial, 29.49% neral, 14.29% α-limonene, 2.29% β-pinene, 1.89% sabinene, 1.89% 1,8-cineole, 1.69% α-pinene, 1.59% α-terpinolene and 1.32% 6-methyl-5-hepten-2-one, as major compounds adding up to 96% of the total profile [The essential oil from  profile .Litsea cubeba EO to the highest counts, 5.50 log CFU/g for the control sample. The average numbers of TVC were significantly lower (p < 0.05) in the samples treated with Litsea cubeba EO in comparison with control groups throughout the storage period, the highest differences were detected at 15 days of refrigerated storage  of deer meat . Average storage .p < 0.05) affected CB counts. Vacuum packaging itself slightly reduced CB counts as compared to aerobically stored meat. The presence of rapeseed oil proved better inhibitory effect than vacuum itself; the addition of 0.5% EO from Litsea cubeba slightly enhanced the preservation effect as compared to rapeseed oil addition. The presence of 1.0% Litsea cubeba EO completely inhibited CB during 20 days of refrigerated storage. Coliforms bacteria (CB) counts are presented in Pseudomonas were detected only in air packaged control group and vacuum packaged control group. The highest number of Pseudomonas was 1.96 ± 0.02 log CFU/g in the aerobic control group and 1.50 ± 0.01 log CFU/g in the control group with vacuum packaging on the twentieth day of storage The average numbers of Pseudomonas were significantly higher (p < 0.05) in the aerobic control group in comparison with control group with vacuum packaging. Pseudomonas was not detected in the control with rapeseed oil, nor in samples treated with 0.5 and 1.0% essential oil from Litsea cubeba (Bacteria of the genus a cubeba .Counts of lactic acid bacteria (LAB)  were kepBacillus cereus was isolated from all groups of samples, Staphylococcus epidermidis and Staphylococcus capitis were isolated from all control groups of samples and S. capitis was isolated from samples treated with 0.5% Litsea cubeba EO. Four species of the genus Pseudomonas  were isolated from control groups of samples. Sphingomonas paucimobilis and Sphingomonas leidyi were isolated from the aerobic control group and from control group with vacuum packaging. S. leidyi was isolated from control group with rapeseed oil and from samples treated with 0.5% Litsea cubeba EO. Brevibacillus borstelensis was isolated from the aerobic control group and Pantoea agglomerans from control group with vacuum packaging. The classification of microorganisms into families is shown in Microbial species were isolated from individual samples . BacilluThe most commonly isolated bacteria belong to the family Pseudomonadaceae (46%). The second most represented family is Staphylococcaceae (19%). The other families represented were Sphingomonadaceae (16%), Bacillaceae (14%), Paenibacillaceae (3%) and Enterobacteriaceae (2%) .Litsea cubeba, the best antimicrobial activity is provided by fruit oil [Litsea cubeba fruit EO citral is known to possess a broad-spectrum antimicrobial activity against various bacteria and fungi. Litsea cubeba EO has a very unique sensory profile [Essential oil can be obtained from several parts of ruit oil . Predomi profile ,24 which profile . In the  profile . They re profile ,21,26, s profile . Convers profile . Other a profile . In the  profile ,23. EvenPseudomonas spp. 3.82 log CFU/g. Borilová et al. [Lactobacillus spp. counts were 3 log CFU/g and TVC counts were 2 log CFU/g at the end of the experiment, such counts are closer to the observed in the present study, being TVC much lower than the present deer samples, probably explained by the low storage temperature of 0 °C of the wild boar meat.When dealing with game meat, scarce data are available on their microbial quality. Peruzy et al.  analysedá et al.  analysedLactobacillus spp., CB, TVC) by 2 log CFU/g, The study concluded that the application of oregano EO to game meat can reduce the number of TVC, coliforms and LAB by about 1.4 times as compared to untreated aerobically packaged meat, and, finally could extend its shelf life by 3 days [In the present study, TVC increased 3–3.5 log CFU/g during 20 days of refrigerated storage almost for all treatments, reaching values between 5 and 5.5 log CFU/g. Other authors reported an increase of TVC by 1 log CFU/g in vacuum-packaged deer meat after 7 days of storage , which iy 3 days . In the Escherihia coli with low (0.125%) concentration of LCEO [Pseudomonas, they were only detected in 20 days stored control aerobic and vacuum stored samples, LCEO effectively inhibited their growth , Pantoea (73%), Escherichia (59%), Acinetobacter (55%), and also a high incidence of Salmonella (32%) (2019) [Escherichia coli serotype from deer meat. They also identified coliforms bacteria E. coli and bacteria of the genus Acinetobacter and Arthrobacter from wild boar meat samples. Maksimovic et al. [Bacillus cereus bacteria from deer sausage samples. The species isolated from game meat in the present study have some similarities: B. cereus and the relevance of Pseudomonas; however the detected profile is quite different, and it is free of coliforms showing a higher hygienic quality of the meat. As can be seen in Limited information is available on the microflora of game meat. Regarding wild boar meat, the most frequently isolated families are ) (2019) . Asakura) (2019)  analysedc et al.  isolatedLitsea cubeba EO applied to game meat in combination with vacuum packaging is highly effective against bacteria from genus Pseudomonas and coliforms. The use of 1.0% LCEO is moderately effective against total viable counts and lactic acid bacteria. The presence of LCEO reduces microbial load and diversity being more effective inhibiting Gram-negative and leaving a microbial ecosystem with prevalence of Bacillus and Pseudomonas. Inactivation of microorganisms in foods enhance food safety and has a positive effect on extending of their shelf life. LCEO, a natural and mild-flavour antimicrobial is suitable for extending the shelf life of vacuum-packaged deer meat. Studies are needed to further enhance the inhibition of total viable counts.Our results show that 0.5% and 1.0%


ObjectiveThroughout the coronavirus disease 2019 (COVID-19) pandemic, multiple factors have been associated with poor prognosis for those infected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. Age, obesity, and medical comorbidities have been linked to poor outcomes, including admission to the intensive care unit (ICU), acute renal failure, stroke, myocardial infarction (MI), mechanical ventilation, and even death for hospitalized COVID-19 patients. Although diabetes mellitus (DM) has also been included in this set of medical comorbidities, there have been inconsistencies in the currently available body of literature, suggesting that mortality rates may or may not be correlated to elevated glycosylated hemoglobin (HbA1c) levels. This study aims to determine whether there is a correlation or trend between a range of HbA1c values and in-hospital mortality among patients admitted to the hospital with a COVID-19 diagnosis.Materials and methodsThis study was a retrospective review of electronic medical records at Arrowhead Regional Medical Center in Colton, CA. Any patient above the age of 18 admitted to the hospital during a predetermined time frame, with either a positive COVID-19 PCR test on admission or during their hospital stay, was included in the study. These medical charts were reviewed for HbA1c values during admission or within three months prior to admission. In-hospital mortality was then recorded for each medical record with an available HbA1c value. Hospital discharge summaries were used to delineate comorbidities, including chronic kidney disease, cerebrovascular disease, coronary artery disease, congestive heart failure, cancer history, or history of deep vein thrombosis/pulmonary embolism among the patients included in the study. Average HbA1c values were recorded for the mortality and non-mortality groups, and their statistical significance was calculated.ResultsIn this retrospective study, HbA1c levels were compared to mortality rates among adult patients admitted to the hospital with a concurrent COVID-19 diagnosis. From the analysis conducted, those with higher HbA1c levels did not have an increased rate of in-hospital mortality, and those with lower HbA1c levels did not have a decreased rate of in-hospital mortality. Comorbidity data as a confounding factor was also reviewed and excluded from the final analysis. The SARS-CoV-2 vaccine was also excluded as a confounder in this study by selecting a specific time frame for data collection. Based on our results, we propose that HbA1c levels likely have little to minimal correlation with mortality rates among hospitalized COVID-19 patients.ConclusionIn this study, we show that HbA1c levels, regardless of concurrent comorbidities, are unlikely to be correlated to mortality rates among hospitalized COVID-19 patients. HbA1c levels should not be used as a marker for whether these patients should be admitted to the hospital for further inpatient management or discharged from the emergency department. SARS-CoV-2, a single-stranded RNA virus in the coronavirus family that causes the COVID-19 infection, was first discovered in Wuhan, China, on January 7, 2020 . Toward HbA1c has been shown to objectively delineate diabetes severity and overall glycemic control over an average of three months . HbA1c lStudy designThe goal of this study was to find the correlation between adult patients admitted to either medical floors or ICU carrying a diagnosis of COVID-19 (confirmed by polymerase chain reaction (PCR) testing of nasopharyngeal swabs for SARS-CoV-2 virus) with their documented HbA1c level. This study was a retrospective review of electronic medical records at Arrowhead Regional Medical Center in Colton, CA. It was reviewed and approved by the Arrowhead Regional Medical Center Institutional Review Board (Protocol# 22-35) on June 17, 2022. All medical records and reviews complied with HIPAA regulations. Patient identifiers were strictly limited to the medical record number, age, sex, ethnicity, body mass index (BMI), past medical history, comorbidities, and outcome of admission (disposition).Inclusion and exclusion criteriaAll the electronic charts were first filtered with basic search criteria. Any patient that was above the age of 18 and was admitted to the hospital (Floors/Wards or ICU) from March 1, 2020, to December 1, 2020, with either a positive COVID-19 PCR test on admission or during their hospital stay was included in the initial search. This was achieved through searching International Classification of Diseases (ICD) codes relevant to a COVID-19 or acute hypoxic respiratory failure due to COVID-19 diagnosis. The reason for choosing this specific time frame was to exclude the effect of the SARS-CoV-2 vaccine as a confounder to mortality data since the vaccine was first available for distribution in December 2020 [Data collectionEach of the selected charts was meticulously reviewed for an HbA1c level obtained during or within three months of the patient’s hospital stay. In-hospital mortality was then recorded for each medical record with an available HbA1c value, regardless of how high or low that value was. Hospital discharge summaries were used to aid in the collection of that individual’s medical history to delineate comorbidities, including chronic kidney disease, cerebrovascular disease, coronary artery disease, congestive heart failure, cancer history, or history of deep vein thrombosis/pulmonary embolism. Average HbA1c values were recorded for the mortality and non-mortality groups and their statistical significance was calculated using a p-value. After data were collected, HbA1c values were stratified in different groups and comorbidity data was excluded from the final calculation of mean values. The data were subsequently organized into a tabular format.Data from electronic medical records at our institution were reviewed from March 1, 2020, to December 1, 2020. Those cases that were above the age of 18, were admitted to the hospital on the floors or ICU, and had a diagnosis of COVID-19 were examined. There were 487 records reviewed in total. There were 193 females (40%) and 294 males (60%) in this cohort, and the median age was 58. Of those 487 cases, 379 of them were included in this study as they had a valid HbA1c level drawn during their hospital stay or within three months prior to their hospital stay. Out of those 379 cases, 87 (22.9%) suffered in-hospital mortality. The average age of these patients was 62.5. The average HbA1c level for mortality cases was 7.66%. HbA1c values for all the cases included were divided numerically from <5% to >14%. The groupings were in intervals of 1 percentage point. For example, 5.0-5.9% was one interval group while 6.0-6.9% was the next. The lowest mortality rate was 15.8% in the 11.0-11.9% HbA1c group. There were 19 cases documented in this group and three deaths. The highest mortality rate was in the > 14% HbA1c group at 33.3%; however, there were only three documented cases and one death. All the other groupings had a mortality rate between 21%-27%. The mortality rates in the 5.0-5.9%, 6.0-6.9%, and 7.0-7.9% HbA1c groups were 21.7%, 22%, and 25.5% respectively. The mortality rates in the 8.0-8.9%, 9.0-9.9%, and 10.0-10.9% HbA1c groups were 25.9%, 20.8%, and 26.9% respectively  patients had at least one documented comorbidity. The remaining 61 (70.1%) patients did not have any documented comorbidity. The comorbidities that were looked for in each case included a history of cerebrovascular disease, coronary artery disease, congestive heart failure, chronic kidney disease, cancer, or deep vein thrombosis (DVT)/ pulmonary embolism (PE). Of those that died in the 5.0-5.9%, 6.0-6.9%, 7.0-7.9%, 8.0-8.9% HbA1c groups, 35%, 33.3%, 25%, 28.6% respectively had at least 1 comorbidity. To account for comorbidities as a confounder in this study, data were filtered to exclude patients with any of the above-mentioned comorbidities. There was a total of 301 cases in that 387 original cohort used in the study for which there was no comorbidity documented as reviewed by physician discharge summaries and progress notes. From this group, there were 61 (20.3%) total deaths. Groupings for each interval were similar to the ones above. The lowest mortality rate was 15.4% in the 9.0-9.9% HbA1c group. There were 13 cases documented in this group and two deaths. The highest mortality rate was in the >14% HbA1c group at 33.3%; however, as mentioned earlier, there were only three documented cases and one death. The <5% HbA1c group and the 11.0-11.9% HbA1c group both had a mortality rate of 16.7%. The mortality rates in the 5.0-5.9%, 6.0-6.9%, 7.0-7.9%, and 8.0-8.9% HbA1c groups were 18.3%, 18%, 25.8%, and 25% respectively. Additionally, the mortality rates in the 10.0-10.9%, 11.0-11.9%, 12.0-12.9%, and 13.0-13.9% HbA1c groups were 25%, 16.7%, 20%, and 25% respectively (Table Our focus in this single-center, retrospective, observational study was to understand the correlation between HbA1c levels and mortality among patients admitted to the hospital with a diagnosis of COVID-19. HbA1c levels generally show the trend of glycemic control for the past three months, therefore illuminating the severity of an individual’s diabetes . Since dOne specific point to consider is that this study was largely inpatient-focused. It did not include outpatient management and control of diabetes prior to hospital admission. Patients with a higher HbA1c may likely have been on diabetic medications previously, including insulin. It is unclear how being on diabetic medications, such as insulin and metformin, in the outpatient setting would affect these results. As noted by Patel et al. in their study, HbA1c values could potentially be skewed in certain populations such as those with chronic kidney disease and/or in patients with anemia, which may affect the accuracy of HbA1c values obtained . One wayThere are numerous avenues for further research into this topic. While particular comorbidities were incorporated into this study, more research could include other comorbidities, including liver and pulmonary diseases, such as cirrhosis and obstructive lung disease. Our study was designed to evaluate a pre-vaccination population and future studies could incorporate data from a broader time period to evaluate a post-vaccination population. Another potential area of focus for future research is the analysis of patients’ outpatient diabetic regimens, including prior insulin or metformin use, and tracking specific inpatient glycemic trends instead of HbA1c values.A key limitation of our study is its single-centered nature, which solely represents the San Bernardino County population in California. Although similar data may be seen in other regions with a similar population, it is hard to generalize this data throughout all populations and regions. Another limitation of this study was that it was hard to delineate COVID-19 as the primary cause of patients' mortality. It was difficult to rule out other comorbidities and complications during the hospital stay that may have played a significant role in the resulting mortality rates, even though physician discharge/death summaries were meticulously reviewed. That said, it is difficult to say with certainty that every single discharge/death summary reviewed in the study accurately reflected all the comorbidities and chronic conditions that the patient may have had in the outpatient setting. Thus, other unidentified comorbidities could have also played a significant role in mortality rates. Additionally, since the vaccine was excluded as a confounding factor, its presence may have modified the data and could change recommendations about specific individuals’ mortality risks.Although comorbidities such as diabetes mellitus can predispose patients to severe COVID-19 disease and even result in hospitalization, there is no clear correlation between poorly controlled diabetes and mortality specifically among patients hospitalized with COVID-19. From this single-center study, higher HbA1c values did not correlate with higher mortality rates among patients who were admitted to the general medical floor or the ICU with a concurrent diagnosis of COVID-19 or respiratory failure due to COVID-19. This suggests that the risk of mortality is not inherently higher in patients with elevated HbA1c values. It also suggests that certain risk factors may not significantly increase the risk of mortality. This type of study can help highlight the need for hospitalization in some patients with COVID-19 regardless of their HbA1c value due to their increased risk of severe infection despite low levels and well-controlled diabetes mellitus. However, further studies are needed to help clinicians delineate whether certain comorbidities are inevitably a greater or lesser risk factor for disease severity in those that acquire COVID-19.


IntroductionCurrent evidence from developed countries on lumbar spine surgeries under regional anesthesia reports it to be superior to general anesthesia (GA) in terms of decreased anesthesia time, operative time, intraoperative complications such as bleeding, postoperative complications, length of hospital stay, and overall cost. We report the first case series from Pakistan on lumbar spine surgeries under regional anesthesia.MethodsWe utilized spinal anesthesia (SA) for lumbar spine surgeries of 45 patients in a tertiary-care hospital in Karachi, Pakistan. The surgeries were performed as day-care procedures. The preoperative assessments included MRI findings, visual analogue scale (VAS), pre-operative limb powers, and straight leg raise (SLR). Other assessments included total SA time, total surgical time, time of stay in the post-anesthesia care unit (PACU), complications, and total hospital cost. SPSS v26 was used to calculate means and standard deviations.ResultsWe found the total SA time to be about 45 to 60 minutes in most patients (95.6%). The total surgical time was 30 to 45 minutes for most patients. The average time of stay in the PACU was three to four hours. The VAS scores were significantly improved postoperatively with 46.7% (n=21) of patients with a score of 3, 46.7% (n=21) with a score of 2, and 6.7% (n=3) with a score of 1. 71.1% (n=32) patients had day-care surgery, 22.2% (n=10) stayed in the hospital for one day, and 6.7% (n=3) patients stayed for more than one day. Most patients  had no complications, whereas only 11.1% (n=5) complained of PDPH. The total hospital cost was also lesser than procedures under GA.ConclusionWe conclude that SA is well tolerated and has favorable outcomes in terms of cost-effectiveness, anesthesia time, surgical time, and hospital stay; therefore, SA should be considered for a greater number of lumbar spine surgeries, especially in low-middle income countries. Lumbar spine surgeries are primarily performed under general anesthesia (GA). This is due to various reasons such as the surgeon’s preference, the anesthesiologist’s inclination, and the patient’s perception of the standard of care. Procedures that may be done in under two hours and do not have a significant risk of excessive blood loss may be performed under spinal anesthesia (SA). Appropriate patients for SA include those with low lumbar spine deformities , non-protuberant abdomens, intact cardiac status (as the prone position of surgery may compromise cardio-pulmonary systems) , and preSA is also more cost-effective than GA ,7, whichAs per the author’s knowledge, there is limited data from low-middle-income countries and South Asia on clinical experience with SA for lumbar spine surgeries. Munasinghe et al. reported the initial cases of two patients who underwent single-level, unilateral lumbar decompressions and discectomy under SA and discussed the importance of patient selection for SA in lumbar spine surgeries . We presEthical considerationsThis study was approved by the Ethics Review Committee, Liaquat National Hospital and Medical College, Karachi, Pakistan. Informed consent was taken from the patients before the procedure. The data was anonymized so that patient identities remain confidential. The study is reported as per CARE guidelines.Patients informationA total of 45 patients were included in our case series, among which 35.5% (n=16) were female and 64.5% (n=29) were male. No co-morbidities were present in 46.7% (n=21) patients, whereas 53.3% (n=24) had diabetes mellitus (n=9); hypertension (n=9); hypothyroidism (n=2); and ischemic heart disease (n=3). 46.7% (n=21) of patients were classified as American Society of Anesthesiologists (ASA) I 53.3% as ASA II, and there were no patients with severe systemic diseases. The mean BMI was 22.74±1.98 kg/m2. The most frequent presenting symptoms were backache (88.89%), pain in lower limbs , numbness in lower limbs , and claudication (44.44%).Diagnostic assessmentThe visual analogue scale (VAS) was used to assess pain. 28.9% (n=13) patients had a VAS score of 9, 66.7% (n=30) had a score of 8, and 4.4% (n=2) had a score of 7 preoperatively.The most common preoperative MRI findings included disc protrusion, narrowing of lateral recess, narrowing of neural foramina, compression of nerve roots, and decreased disc height. 51.1% (n=23) patients had MRI abnormalities in a single spinal level, 35.6% (n=16) in two levels, and 17.8% (n=8) in multiple spinal levels.Surgical procedureFollowing the diagnosis, all patients underwent conservative management of six weeks to two months which included analgesia with nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and/or gabapentin/pregabalin, along with adequate physiotherapy. Patients who failed to show a response to conservative management or had significant deficits affecting the quality of life were selected for surgical management. Patients were admitted on the day of the surgery following anesthesia assessment. Once the patients were shifted to the operating room, they were placed in the seated position and attached to ECG monitoring, noninvasive blood pressure, pulse oximetry, and a cutaneous temperature probe. SA was administered using lumbar puncture by a pencil-point needle, and 0.75% bupivacaine in an 8.5% dextrose solution. As bupivacaine is hyperbaric, it was administered one level above or below the deformity. No spinal canal stenosis was found in any patient and supplemental analgesia or sedation was not required. Motor block was assessed by asking the patient to raise his/her limb, whereas sensory block was assessed by asking for numbness in the limb. Once the block was effective, the patients were rolled into the supine position and allowed to rest until a stable spinal level was achieved. After an adequate block was documented, the patient was turned into the prone position on the operating table and placed in either the flexed or knee-chest position. Upper body and upper extremity positioning were modified to patient comfort, and the patients were placed on a pillow to allow easy breathing and to relieve anxiety about having their faces covered. Oxygen administration was provided by the nasal cannula and at a flow of 2 L/min. After the procedure, the propofol was not given, and the patients were rolled from the prone position onto the recovery bed and transferred to the PACU with O2 by nasal cannula. The time for spinal anesthesia was assessed from the beginning of the sensory block to the time the patients could move their limbs, and was compared with the time taken by GA. All the procedures were performed by the same surgical and anesthesia team.The specific procedures are enlisted in Table OutcomesThe total spinal anesthesia time was 45 minutes in 46.7% (n=21), 60 minutes in 48.9% (n=22), and 90 minutes in 4.4% (n=2). The total surgical time was 30 minutes in 46.7% (n=21), 45 minutes in 48.9% (n=22), 60 minutes in 2.2% (n=1), and 90 minutes in 2.2% (n=1). The total time of stay in the post-anesthesia care unit (PACU) was three hours in 46.7% (n=21), 48.9% (n=22) had a total time of stay of four hours, and only two stayed for five hours.Common postoperative complaints included back pain in 46.7%; 17.8% (n=8) complained of both back pain and leg pain, 2.2% (n=1) complained of back pain and nausea, 11.1% (n=5) complained of leg pain, 2.2% (n=1) complained of nausea, and 20.0% (n=9) patients have no postoperative complaint.The VAS scores were improved due to the surgical correction of the underlying pathology. Postoperatively, 46.7% (n=21) had a VAS score of 3, 46.7% (n=21) had a VAS score of 2, and 6.7% (n=3) had a score of 1; signifying improvement in a major symptom.Day-care procedures were done in 71.1% (n=32). Around 22.2% of the patients (n=10) stayed in the hospital for one day, and 6.7% (n=3) stayed for more than one day. No complications occurred in 88.9% (n=40), whereas only 11.1% (n=5) complained of spinal headaches or PDPH which was reported by the patients in their first follow-up. The patients were given instructions about potential complications such as PDPH along with their management.The total hospital cost was $360 for 48.9% (n=22); $450 for 33.3% (n=15); and $540 for 17.8% (n=8) patients. The cost was lower than that of surgeries done under GA which cost $900-$1125.We report the initial case series of SA for lumbar spine surgeries from a single institution in Pakistan. Our experience indicates that SA is safe, takes lesser time, and has minimal to no complications in lumbar spine surgeries.Pierce et al. conducted a retrospective analysis comparing SA to GA for laminectomy and/or diskectomy spinal surgery and reported lower operative time, blood loss, total anesthesia time, the total time for surgery, and duration of hospital stay, however, a longer stay in the PACU was reported . Attari Munasinghe et al. reported cases of two unilateral L4-5 decompression and discectomy with satisfactory surgical outcomes. They discussed a lower rate of postoperative complications and the importance of selecting appropriate cases. Multi-level canal stenosis or complicated cases require bilateral dissections which prolonged operative time thus single or two-level decompression should undergo SA. Other unsuitable candidates include obese patients, the elderly, multiple comorbidities, and children who might not cooperate with prolonged prone positioning . SA howeLee et al. listed and compared the advantages of both regional and general anesthesia and recommended that regional anesthesia should be the standard of practice in lumbar spine surgeries . West etOur study had a limited population as this study was based on a single center. The surgeon satisfaction and patient satisfaction were not quantitatively assessed. The postoperative follow-up was limited as the patients had to travel long distances for it. We recommend conducting lumbar spine surgeries under SA and further studies in SA in the developing world.Even though lumbar spine surgeries under GA are the norm, this case series provides the feasibility of SA for lumbar spine surgeries. SA is well tolerated and has favorable outcomes in terms of anesthesia time, surgical time, and hospital stay. Our study replicates the findings of the previous literature comparing GA and SA.


Incomplete and inconsistent reporting of adverse events (AEs) through multiple sources can distort impressions of the overall safety of the medical interventions examined as well as the benefit-risk relationship. We aimed to assess completed allergic rhinitis (AR) trials registered in ClinicalTrials.gov for completeness and consistency of AEs reporting comparing ClinicalTrials.gov and corresponding publications.We retrospectively examined completed randomised controlled trials on AR registered in ClinicalTrials.gov on or after 9/27/2009 to trials updated with results on or before 12/31/2021 along with any corresponding publications. Complete reporting of AEs in ClinicalTrials.gov were summarised in tables describing AE information, and complete reporting in publications was an explicit statement of serious AE, death or other AE. Difference in completeness, number, or description of AEs between ClinicalTrials.gov and publication was classified as inconsistent reporting of AEs.(P < .001). In 43 (95.6%) publications, there was at least one inconsistency in the reporting of AEs (P < .001). 8 (17.8%) publications had different number of serious AEs (P = .003), 36 (80.0%) of other AEs (P < .001) while deaths reporting was inconsistent in 8 (57.1%) publications (P = .127).There were 99 registered trials with 45 (45.5%) available publications. All published trials completely reported AEs in ClinicalTrials.gov, and 21 (46.7%) in publications The reporting of AEs from AR trials is complete in ClinicalTrials.gov and incomplete and inconsistent in corresponding publications. There is a need to improve the reporting of AEs from AR trials in corresponding publications, and thus to improve patient safety. The reporting of adverse events (AEs) to ClinicalTrials.gov has been mandatory since September 2009 . The SecGlobal health and at the same time economic problems can be attributed to allergic rhinitis (AR), for which drugs are the mainstay therapy, require numerous clinical studies . The datWe retrospectively analysed completed RCTs on AR shown in Fig. We searched ClinicalTrials.gov for completed RCTs using the following keywords: “allergic rhinitis”, “nasal allergies”, “rhinoconjunctivitis”, “hay fever”, and “atopic rhinitis”. We did not use Medical Subject Headings (MeSH) interventions. For trials with publications provided on ClinicalTrials.gov, we selected only those that reported the results of the current trial as the corresponding publications to the RCTs on AR. For trials without publications provided, we searched PubMed, Web of Science, Scopus and Google Scholar with the National Clinical Trial (NCT) identifier provided by ClinicalTrials.gov in the trial record that is usually listed in the abstract or main text of published articles . If the FDAAA: The Food and Drug Administration Amendment Act, FDA: The Food and Drug Administration.Flow diagram of retrospective cross-sectional study with inclusion and exclusion criteria. Inclusion criteria are shown in Fig. We primarily analysed the completeness and consistency of AEs reporting in ClinicalTrials.gov and the corresponding publications. The complete reporting of AEs in the registry were tables with the number of participants affected out of those at risk summarised for each AE, as required by the Final Rule . AdditioP < .05.Data extracted from ClinicalTrials.gov were coded and then entered into a Microsoft Excel spreadsheet. Percentages, medians with the 95% CIs were presented. Two-level categorical variables (no or yes) were different SAEs description, SAEs reported in a publication, SAEs reported as zero in a publication, OAEs reported as Treatment-emergent AEs (TEAEs) and as Treatment-related AEs (TRAEs) in a publication. The number of OAEs, frequency threshold and elapsed time from posting results to publication were treated as nonparametric. We categorised these nonparametric values based on a median split, where values were dichotomised as 0, when less than or equal to their respective median, and as 1 when greater than their respective median. Differences between ClinicalTrials.gov and publications in the completeness and consistency of reporting of AEs, their reported number or description were compared using the Chi-square test or Mann-Whitney U test. Frequencies were compared using Chi-squared tests. We used IBM SPSS Statistics 21  for the analyses. Differences were considered significant at a (P < .001). In 43 (95.6%) publications, there was at least one inconsistency in the reporting of AEs compared to ClinicalTrials.gov (P < .001). Table There were 99 registered trials with 45 (45.5%) available publications. Of the published trials, most were phase 3 (n = 21 [46.7%]), followed by phase 2 and 4 with 10 (22.2%) trials each. Furthermore, 34 (75.6%) of them were industry-sponsored trials, and 20 (44.4%)The withdrawal of participants due to AEs  was explicitly stated in most publications (n = 43 [95.6%]). In 5 (11.1%) publications, the number of patients withdrawn due to AEs differed from the corresponding number in ClinicalTrials.gov, and in most cases (n = 4 [8.9%]) was higher than in ClinicalTrials.gov.(P = .003), of which 1 (2.2%) publication reported a higher number than in ClinicalTrials.gov, and 7 (15.6%) had a smaller number. The number of patients with at least one SAE differed in 7 (15.6%) publications compared to the corresponding number in ClinicalTrials.gov (P = .006), and all 7 publications reported a smaller number than in ClinicalTrials.gov. In 15 (33.3%) publications the description of reported SAEs differed from the corresponding ones in ClinicalTrials.gov. Furthermore, trials in which less time elapsed from the posting of results in ClinicalTrials.gov to publication  were more prone to different descriptions of SAEs in publications, χ2 = 10.476, P = .001. Additionally, authors of publications corresponding to trials with zero reported SAEs in ClinicalTrials.gov were more likely to omit explicit reporting of SAEs in publications, χ2 = 4.746, P = .029.In 8 (17.8%) publications, the number of reported SAEs differed from the corresponding number in ClinicalTrials.gov (P < .001), of which 12 (26.7%) publications reported a smaller number than in ClinicalTrials.gov, and 24 (53.3%) had a higher number. In 37 (82.2%) publications, the description of reported OAEs differed from the corresponding ones in ClinicalTrials.gov.17 (37.8%) publications reported OAEs only as TEAEs2 = 14.400, P < .001 and χ2 = 9.000, P = .003, respectively. The number of patients with at least one OAE differed in 33 (73.3%) publications compared to the corresponding number in ClinicalTrials.gov (P < .001). Of these, a smaller number of patients with OAEs were reported in 7 (15.6%) publications, and a higher number in 26 (57.8%). The median reported frequency threshold in ClinicalTrials.gov was 5% (95% CI 2.77–4.09) and in publications 0% (95% CI 0.58–2.11) indicating a lower frequency threshold report in publications than in ClinicalTrials.gov. Furthermore, 26 (57.8%) publications had different frequency thresholds, mostly (n = 24 [53.3%]) lower than in ClinicalTrials.gov. Additionally, significantly more publications with a lower frequency threshold than registered had more reported OAEs than in ClinicalTrials.gov, χ2 = 6.259, P = .012.In 36 (80.0%) publications, the number of reported OAEs differed from the corresponding number in ClinicalTrials.gov (P = .001) (Table (P = .127).35 (77.8%) published trials were completed before the implementation of the Final Rule, and 10 (22.2%) after. 17 (37.8%) pre-Rule trials reported deaths in corresponding publications while only 2 4.4%) trials reported deaths as SAE and 2 (4.4%) through the ACM table in ClinicalTrials.gov. In contrast, all post-Rule trials reported deaths in ClinicalTrials.gov through the ACM table while only 4 (40.0%) corresponding publications reported deaths. Overall, 14 (31.1%) published trials reported deaths in ClinicalTrials.gov and 21 (46.7%) in publications. Thus, discrepancies in reporting of deaths was analysed for 14 (31.1%) published trials where we found that all of them reported deaths in ClinicalTrials.gov, and only 6 (42.9%) in corresponding publications as well .4% trialOur novel cross-sectional study on the discrepancies in the reporting of safety data from RCTs on AR showed incomplete and inconsistent AEs reporting in corresponding publications. Most published trials were phase 2, 3 and 4 (n = 42 [93.3%]) and were published in high-impact journals. Therefore such publications should contain consistent and complete data in relation to the registry as they have the greatest impact on clinical care and formulation of clinical practice guidelines . A similAlmost a quarter of the analysed publications did not explicitly report SAEs, and it is evident that publications mostly underreported SAEs as well as participants affected by SAEs in relation to ClinicalTrials.gov. As already stated in the results, one of the reasons for omitting explicit reporting of SAEs is definitely their absence during the trial, reported as zero in ClinicalTrials.gov. A number of other authors have found similar discrepancies in SAEs reporting between ClinicalTrials.gov and corresponding publications –6. The fJurić et al. ) had inconsistent reporting compared to ClinicalTrials.gov. Unlike SAEs underreporting, we found the overreporting of OAEs as well as participants affected by OAEs in the publications. One of the reasons for reporting more OAEs in publications is a lower frequency threshold at which to report OAEs in more than half of the publications. A similar conclusion was reached in the study by ć et al. . Discrepications . We haveications , but verThe analysis of the reporting of deaths differed from the analysis of remaining adverse events due to different regulations and requirements in their reporting during the analysed period. Therefore, discrepancies in deaths reporting has been analysed in less than a third of published trials, and the underreporting of deaths found in publications supports the results of other studies that analysed discrepancies in the reporting of AEs between trial registry and publications , 23. TheWe analysed trials only registered in ClinicalTrials.gov. There are currently 17 other primary registries in the World Health Organization (WHO) registry network that meet International Committee of Medical Journal Editors (ICMJE) requirements and therefore our analysed data may be incomplete and inaccurate . HoweverThe reporting of AEs from completed and published AR trials is complete in ClinicalTrials.gov and incomplete and inconsistent in corresponding publications despite all recommendations and guidelines. The SAEs and deaths were underreported in publications while OAEs were overreported. Inconsistent and incomplete reporting of AEs in publications compromises patient safety so there is a need for a more detailed comparison of registered and submitted AEs during the publication process.


The aim of this research was to compare the biomechanical properties of experimental composites containing a classic photoinitiating system (camphorquinone and 2-(dimethylami-no)ethyl methacrylate) or diphenylphosphine oxide (TPO) as a photoinitiator. The produced light-cured composites consisted of an organic matrix-Bis-GMA (60 wt.%), TEGDMA (40 wt.%) and silanized silica filler (45 wt.%). Composites contained 0.27; 0.5; 0.75 or 1 wt.% TPO. Vickers hardness, microhardness (in the nanoindentation test), diametral tensile strength, resistance to three-point bending and the CIE L* a* b* colorimetric analysis was performed with each composite produced. The highest average Vickers hardness values were obtained for the composite containing 1 wt.% TPO (43.18 ± 1.7HV). The diametral tensile strength remains on regardless of the type and amount of photoinitiator statistically the same level, except for the composite containing 0.5 wt.% TPO for which DTS = 22.70 ± 4.7 MPa and is the lowest recorded value. The highest average diametral tensile strength was obtained for the composite containing 0.75 wt.% TPO (29.73 ± 4.8 MPa). The highest modulus of elasticity characterized the composite containing 0.75 wt.% TPO (5383.33 ± 1067.1 MPa). Composite containing 0.75 wt.% TPO has optimal results in terms of Vickers hardness, diametral tensile strength, flexural strength and modulus of elasticity. Moreover, these results are better than the parameters characterizing the composite containing the CQ/DMAEMA system. In terms of an aesthetic composite containing 0.75 wt.%. TPO is less yellow in color than the composite containing CQ/DMAEMA. This conclusion was objectively confirmed by test CIE L* a* b*. In every branch of medicine doctors use golden means to treat their patients, but is it always the best solution for every situation? In operative dentistry, especially dental materials, dentists use most often composites to fill most of the dental cavities. Do dentists focus on ingredients of composite they use? Is it possible that 1% of a whole composite can change the aesthetic and quality of dental composite? Dentists accepted the advantages and disadvantages of golden mean which is camphorquinone. The technology and science are continuous and rapid processes, which evolve every year. Perhaps modern dentists will not have to compromise between quality and aesthetics aspects.Camphoroquinone (CQ) is well-known photoinitiator used in most dental composites since 1975  and the The photoinitiator worth attention is diphenylphosphine oxide (TPO). TPO is type-1 photoinitiator, which does not require additional initiators such as tertiary amines ,14,16. EMost articles referring to modified photoinitiator systems have investigated one concentration of TPO and compared it with CQ and different tertiary amines ,21,23,242, 1450 mW/cm2 and 3200 mW/cm2) and a light range of 395–510 nm. After multiple tries, the optimal curing duration was 20 s per 2 mm of material high. After this, the samples had optimal features.The compositions of the experimental composites that were tested in this study are shown in The samples that were used to hardness and diametral tensile strength testing were cylindrical (3 mm high and 6 mm diameter). The material was put into silicon molds and then irradiated on both sides. The Vickers hardness (HV) test was performed as a first examination. Eleven samples were tested of every composite. It was determined with semiautomatic hardness tester . The diamond shape as a square-based pyramid with apex angle 136 degree is used and the indenter was loaded with 9.81 N. The contact of pyramid and sample was 10 s.The microhardness of the composites was tested with the NanoTest 600  using a Berkovich indenter. The maximum force was 10 mN, the loading and unloading speed was dP/dt = 0.5 mN/s. The measurements were carried out in controlled conditions of temperature (T = 20 °C) and relative humidity (60 ± 5%). The samples that were tested was 2 mm high and 10 mm in diameter. The composite microhardness and reduced modulus were calculated on the basis of the unloading curve using the procedure proposed by Olivier and Pharr . The disDTS—diametral tensile strength (MPa);P—load applied (N);D—diameter of sample (mm);T—high of sample (mm).The diametral tensile strength test (DTS) assesses the tensile properties of the dental composite materials. Eleven cylindrical samples (diameter 6 mm and thickness 3 mm) were tested of every composite. DTS is the maximum resistance against loads tending to destroy a sample. The crosshead speed was 2 mm/min. The examination was determined with universal testing machine . The numerical value is calculated according to the following formula (1):Flexural strength was performed on a three-point bending test. Six samples were tested of every composite. The samples used in this test were rectangular (25 mm × 2 mm × 2 mm), and they were irradiated at 3 points twice for 20 s on both sides: In total, the sample was irradiated for 120 s. The samples were then placed on two supports 20 mm apart. A force was applied in the middle, downwards at a 90° angle. The test was evaluated in a universal testing machine , the crosshead speed was 1 mm/min and the examination complied with ISO regulations . The maxFlexural strength (MPa) was defined with following Equation (2):W—force, which caused the destruction of the sample (N);l—distance between supports, 20 mm;b—width of sample (mm);h—high of sample (mm).The last examination which was performed was CIE L* a* b* color system on spectrophotometer KONICA MINOLTA CM-3600A (Germany). Every color can be described by three values: hue, brightness and saturation. This test was performed on cylindrical samples (2 mm height and 10 mm diameter) that were cured before testing. The three measurement were made for each composite. The spectrophotometer was calibrated in accordance with the manufacturers’ recommendation. The control group was sample containing CQ and DMAEMA as a photoinitiator system. System CIE L* a* b* contains three axes: a* and b*, which are at right angles to each other and define the basic colors. The third axis L* means brightness and it is perpendicular to plane created by axes a* and b*. A scale of axis a* is from −120 (green color) to +120 (red color). A scale of axis b* is from −120 (blue color) to +120 (yellow color). The scale of axis L* is from 0 (black saturation) to 100 (white saturation). System CIE L* a* b* assumes considering the differences between colors on basis of the distance between points in the three-axes spatial layout.p = 0.05.For the statistical analysis of the results, Microsoft Excel from the Microsoft Office 2010 and Statistica v. 13  were used. To evaluate the distributions of particular parameters, the Shapiro–Wilk test of normality was applied. In cases of nonnormal distribution, the Kruskall–Wallis test was used. In case of normal distribution of particular parameters, the equality of variances was assessed with the use of Levene’s test. For equal variances, ANOVA with Scheffe’s post hoc test was applied. The accepted level of significance was p-value = 0.00000) of manufactured composites. The post hoc Scheffe’s test showed statistically significant differences , with higher values of experimental composite with 0.27 wt.% TPO.Composite including CQ and 0.27 wt.% TPO , with higher values of experimental composite with 0.5 wt.% TPO.Composite including CQ and 0.5 wt.% TPO , with higher values of experimental composite with 0.75 wt.% TPO.Composite including CQ and 0.75 wt.% TPO , with higher values of experimental composite with 1 wt.% TPO.Composite including CQ and 1 wt.% TPO , with higher values for material with 1 wt.% TPO.Composite containing 0.27 and 1 wt.% of TPO . The post hoc Scheffe’s test showed statistically significant differences , with higher values for composite with 0.75 wt.% TPO.Composite containing TPO 0.5 wt.% and 0.75 wt.% of TPO , with higher values of material with 1 wt.% TPO.Dental material including TPO 0.5 wt.% and 1 wt.% of TPO . The results are shown in p-value = 0.00023). The increasing values of flexural strength modulus are connected with higher concentration of TPO. The post hoc Scheffe’s test showed statistically significant differences , with higher values of experimental composite with 0.75 wt.% TPO.Composite including CQ and 0.75 wt.% TPO , with higher values of material with 0.75 wt.% TPO.Material with 0.27 wt.% and 0.75 wt.% TPO , with higher values in TPO 0.75%.Composites including TPO 0.5% and TPO 0.75% . The post hoc Scheffe’s test showed statistically significant differences between:p-value = 0.00015), with higher values of material including CQ,Composite with CQ and 0.5 wt.% of TPO , with higher values of composite with CQ,Materials containing CQ and 0.75 wt.% TPO , with higher values of material with CQ,Dental resin composite including CQ and 1 wt.% TPO , with higher values of material with 0.27 wt.% of TPO,Composite containing 0.27 wt.% and 0.5 wt.% TPO , with higher values of composite including 0.27 wt.% of TPO,Resins with 0.27 wt.% and 0.75 wt.% of TPO , with higher values of material with 0.27 wt.% of TPO,Dental materials with 0.27 wt.% and 1 wt.% of TPO , with higher values of resin containing 0.5 wt.% of TPO.Composites with 0.5 wt.% and 1 wt. % . The post hoc Scheffe’s test showed statistically significant differences , with higher values for resin with CQ.Composite containing CQ and 0.27 wt.% TPO , with higher values for material with CQ.Dental resin including CQ and 0.75 wt. %TPO , with higher values for composite with 1 wt.% of TPO.Material with CQ and 1 wt.% TPO , with higher values for resin with 0.5 wt.% of TPO.Dental composite including 0.27 wt.% and 0.5 wt.% TPO , with higher values for composite 1 wt.% of TPO.Resin based composite with 0.27 wt.% and 1 wt.% TPO , with higher values for resin based composite with 1 wt.% of TPO.Material containing 0.5 wt.% and 1 wt.% TPO , with higher values for material containing 1 wt.% of TPO.Composite with 0.75 wt.% and 1 wt.% TPO . The cement containing CQ and amine has higher values of tensile strength than TPO. The mean results for layer 0.7 mm for CQ was 28.296 ± 2.54 MPa and for TPO was 22.356 ± 2.42 MPa. For layer 1.5 mm for CQ was 21.566 ± 2.70 MPa and for TPO 14.896 ± 3.60 MPa . ConsideThe results of three-point bending strength test did not show significant statistical differences between all composites. However, the highest values of flexural strength has composite containing 0.75 wt.% of TPO. This composite has also the highest values of FS modulus. Randolph et al. shows also that dental resin containing TPO (0.42 wt.%) has higher flexural modulus than material with CQ with dimethylaminoethylmethacrylate (0.2/0.8 wt.%) regardless of the time exposure and the power of dental curing unit . DelgadoThe last examination was CIE L* a* b*. This method is indicated for determination the shade of dental materials, not only composites but also ceramic and let scientists compare these material shades with color of dentine or enamel of natural teeth. The axis a* refers to color green and red. There was also significant statistical difference in values of a*. The CQ/DMAEMA is a control group and reference point. The color of composite with CQ/DMAEMA is closer to red, so this hue is warmer than the hue of composites containing TPO in concentrations 0.5 wt.%, 0.75 wt.%, and 1 wt.%. However, the composite containing 0.27 wt.% TPO has hue values deviated to green color. The closest values to red had composite including 1 wt. % of TPO. Axis b* refers to yellow and blue. The composite containing CQ/DMAEMA has color values closer to yellow than composites containing TPO in concentration 0.27 wt.%, 0.5 wt.% and 0.75 wt.%. The hue of composite including 0.27 wt.% TPO were the most distant from yellow. In contrast, composite containing 1% TPO had the closest values to yellow, even closer than CQ/DMAEMA. The lower the concentration of TPO, the less yellow the composite. Bertolo et al.  also anaAll the composites were tested to assess the most important mechanical properties, and the hues of the composites were also rated. The concentration of photoinitiator influenced the Vicker’s hardness value. Additionally, samples containing TPO had better hardness values. There was also a noticeable influence of type and concentration of photoinitiator on the diametral tensile strength. To sum up: the best mechanical and aesthetic properties were found in the composite containing 0.75 wt.% TPO as a photoinitiator. This composite had higher microhardness, diametral tensile strength, flexural strengths and modulus of elasticity than the composite with the conventional/often used photoinitiator system, i.e., CQ with tertiary amine. Not only were the mechanical properties better, but this composite was less yellow than material with CQ/DMAEMA. However, to answer the question in the title, more tests on the composite with TPO need to be done, i.e., conversion degree measurements, shrinkage stress analysis and material cytotoxicity tests.