Streptococcus pneumoniae is leading bacterial cause of community acquired pneumonia and according to World Health Organization, responsible for 14 % death in children. There is effective vaccine available against Streptococcus pneumoniae. Hence the primary objective was to isolate Streptococcus pneumoniae from nasopharyngeal swabs in children aged 2–59 months with and without community acquired pneumonia and to assess their serotypes.Streptococcus pneumoniae and incubated in a jar at 370 for 18–24 hrs. Quellung reaction test was used for serotyping.This case-control study was conducted in tertiary teaching institutes in northern India. Hospitalized children, aged 2–59 months, with World Health Organization-defined community acquired pneumonia were included as cases. Age matched healthy controls were recruited from immunization clinic. All enrolments were done after written informed parental consent. Nasopharyngeal swabs were taken from both cases and controls, and were cultured on 5 % sheep blood agar with gentamycin plate for growth of Streptococcus pneumoniae positivity in nasopharyngeal swab was 8.1 % in cases, of which 56.8 % were vaccine serotypes and 23.6 % in controls, of which 37.8 % were vaccine serotypes. Adjusted odds ratio of isolating vaccine serotypes among cases as compared to controls was 1.77 .From March 2017 to December 2022, 2693 children (1910 cases and 783 controls), were recruited. The median age of cases was 7 months and controls 10 months. Almost all the cases had received antibiotics prior to hospitalization. Streptococcus pneumoniae isolation from nasopharyngeal was found to be in lower proportion in cases as compared to control, though colonization with vaccine serotypes was higher in cases as compared to control. Therefore, pneumococcal vaccine coverage must be increased to prevent community acquired pneumonia. SP is the leading bacterial cause of CAP in absence of vaccination against it. SP are carried in nasopharynx and go down the respiratory tract causing pneumonia. Therefore our rationale was to assess NP carriage of SP in healthy children and cases of CAP.The circulation dynamics of SP are not well known in low and middle income countries since studies are few in these regions. NP carriage rates and their circulating serotypes in the community, particular in children aged <5 years provides useful information for targeting populations for vaccination and future prevention strategies 2This cross-sectional multi-centric study was conducted from March 2017 to December 2022 in North Indian states of Uttar Pradesh (Etawah and Lucknow districts) and Bihar (Patna and Darbhanga districs) in children aged between 2 and 59 months after obtaining ethical clearance from the ethics committee of participating institutions and approval of Health Ministry Steering Committee of Indian Council of Medical Research, New Delhi. The development of standard operating procedure, data collection forms, customized, web based data management software were developed and validated.The data was collected from two tertiary care hospitals from Lucknow, two from Etawah (1 private and 1 tertiary) and one tertiary hospital from Patna and Darbhanga each. Questionnaire was designed to collect information on the status of immunization, socio-demographic, clinical variables, history of presenting symptoms and duration, examination at the time of hospitalization, and whether had the child received medications for the illness, and were the medicines given orally by and/or by injection, prior use of antibiotics and anthropometric measurement. Research team recruited cases from hospitals daily from each study sites based on inclusion criteria. Data was collected from the hospital record files and we obtain the second copy of the x-ray of included patients. Further, chest x-rays were digitalized and interpreted by panel of trained radiologist 3“presence of cough and/or difficulty breathing, where the respiratory rate is above age specific range, with or without chest in-drawing is classified as pneumonia. However, children with presence general danger sign namely not able to drink, persistent vomiting, convulsions, lethargic or unconscious, stridor in calm child or severe malnutrition are classified as severe or very severe pneumonia” This was a case-control study. Hospitalized cases were recruited from the pediatrics wards. WHO has guidelines for the identification of cases of CAP. According to the guidelines, CAP was defined 3.1Children aged 2–59 months, with symptoms and signs WHO-defined CAP with lower chest in-drawing and severe CAP, residing in the study district whose parents consent for participation were recruited in the study.3.2Children whose cough and respiratory symptoms were there for >14 days (to exclude tuberculosis), whose pleural tap/ intercostal drainage had been done prior to hospitalization, who had been admitted within 14 days of discharge from a hospital facility  were excluded in the study.3.3Healthy children aged 2–59 months, whose parents consented for participation, residing in the study district were recruited as controls.3.4Those with WHO defined CAP or with cough and respiratory symptoms, or diagnosed with any other acute or chronic illness or had received antibiotics in the last 4 weeks were excluded.3.5NP specimens were collected from children by sterile nylon flocked flexible swabs . Immediately swabs were placed in 1.0 ml skimmed milk-tryptone-glucose-glycerol transport (STGG) medium and placed in an ice box as per the WHO consensus methods 3.6NP swabs were cultured on 5 % sheep blood agar  and 5 % sheep blood agar with gentamycin  for growth of SP and incubated in a candle jar at 37 °C for 18–24 h. All pneumococcal isolates were identified by standard microbiological methods 3.7Quellung reaction test was done by using SP isolates of fresh culture. A sterile loopful of the cells of fresh culture were suspended in 50 ul of 0.85 % saline to prepare a suspension. Subsequently, 2 ul of the suspended cells were added on to a glass slide and mixed with 5ul of pooled antiserum and 5 ul methylene blue. These were mixed with a pipette tip. The suspension was covered with the cover slip and incubates at room temperature for 10–15 min. The glass slide was swirled gently while observing for any agglutination reaction until a positive reaction was observed with various pooled antisera. The process was repeated with individual groups with various antisera pools until a positive reaction with the particular serotype specific antisera was observed 3.7.1On the basis of the previous study, the prevalence of the SP in NP of children in Lucknow under 5 years of age among CAP was 34.4 % and in healthy was 41.7 % 3.7.2U test. The number and percentage was calculated for categorical variables with comparison using chi-square or Fisher’s exact test. A p-value of <0.05 was taken as statistically significant using two-tailed distribution. Statistical package of Social Science  software was used to perform all statistical analysis. The number and proportion of all vaccine and non-vaccine serotypes among cases and controls were reported individually.Sociodemographic, clinical and laboratory data were entered online in customized software. Sociodemographic variable such as age (in months), gender, and PCV13 status, mother’s education, and immunization status (excluding PCV) of children aged 2–59 months were compared among cases and controls as well as in SP positive cases and controls. Continuous variable were reported as median and interquartile range (IQR) and compared using Mann-Whitney Univariate analysis and multivariate logistic regression analysis was used to assess the association of VST for SP in cases as compared to controls. The unadjusted odds ratio (OR) and adjusted OR with 95 % confidence interval (CI) of isolating VST among cases as compared to controls was calculated. Those variables that had univariate association with p-value <0.1 with SP positive cases vs controls were used in the multivariate logistic regression model.3.7.3. The median age of children was 10 months . Of all recruited cases, 98.3 % (1877/1910) had already taken the prior antibiotics. SP positivity of NP swab was 8.1 % (155/1910) in cases and 23.6 % (185/783) in controls. Comparison of variables among cases and controls are given in From March 2017 to December 2022, 2693 children were included of which 1910 were cases and 783 controls. Among cases, 25.7 % (490/1910) were PCV vaccinated of which, 5.3 % (26/490) were SP positive; among 74.3 % (1420/1910) children without PCV, 9.1 % (129/1420) were SP positive. Among control, 59.8 % (468/783) were PCV vaccinated of which, 21.8 % (102/468) were SP positive; among 40.2 % (315/783) children without PCV, 26.3 % (83/315) were SP positive. Flow chart of the study given in Fig. 1Distribution of SP serotypes in nasopharynx among cases and controls is shown in Comparison of variables among cases and controls with nasopharyngeal SP positivity were shown in Unadjusted odds of isolating VST of SP among cases was 2.16 , and adjusted odds was 1.77 , adjusted for immunization (excluding PCV), and PCV vaccination status.4This prospective, multicenter, case-control study was done to assess NP carriage of SP in cases of pneumonia and healthy controls. In our study, while SP positivity in cases were found to be lower in proportion as compared to control, isolation of VSTs of SP were significantly associated with cases. The adjusted odds ratio of isolating VSTs of SP among cases was 1.77 .In the current study we found 8.1 % carriage rate of SP in NP in cases as compared to 23.6 % in controls. The reported prevalence of SP carriage among healthy children in India ranged from 6.5 to 69.8 % We found that VST were isolated from 56.8 % of cases and 37.8 % in controls. A study by Cédric Dananch et-al reported 33.3 % to 75.9 % of PCV 13 serotype isolated from cases while in control 40.2 % to 78.1 % PCV13 is effective in reducing the incidence and severity of pneumonia and other lower respiratory infections in children Since 2021, PCV10 produced in India is replacing PCV13 which was given by GAVI to the country 4.1The study has several strengths. We compared the serotype data among cases and controls. Serotyping was done by Quellong method which is the gold standard method for pneumococcal capsular serotyping. Limitation of the study was that we could not collect the NP swab of children prior to their receiving antibiotics. Healthy controls were only recruited in Lucknow. No attempt was made to find the etiology of CAP.4.2Since cases had received prior antibiotics, SP in NP was found to be in lower proportion among them as compared to control. The colonization with VST of SP was significantly higher in cases as compared to controls. Therefore, pneumococcal vaccine coverage must be increased to prevent community acquired pneumonia.Ethical approvalThe study was approved by the Institutional Ethics Committee of King George‘s Medical University, Lucknow vide letter no. 2800 Ethics/R Cell-14 dated 22nd November, 2014.Consent to participateThe caregivers/guardians of children signed the written, informed consent for participation in this study.Code availabilityNot applicable.N. Verma: Investigation, Data curation, Writing – original draft, Writing – review & editing. P. Gupta: Methodology, Investigation, Resources, Writing – original draft, Writing – review & editing, Supervision, Project administration. A.K. Pandey: Data curation, Writing – original draft. S. Awasthi: Conceptualization, Methodology, Investigation, Resources, Writing – original draft, Writing – review & editing, Supervision, Project administration.The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Prof. Shally Awasthi reports financial support was provided by Bill & Melinda Gates Foundation.


The XEN gel stent was developed to reduce the risks of filtration surgery by standardizing the outflow of aqueous humor into the subconjunctival space. Recently, a modified version of the XEN63 gel stent was introduced. The goal of this study was to assess its efficacy and safety.This is a prospective, nonrandomized, observational, consecutive case series study at a single tertiary centre. Patients with open-angle glaucoma with above target intraocular pressure (IOP) despite maximal tolerated medication were included. The primary outcome was a change of median IOP. Secondary outcomes included a change in the number of medications, complete success, needling and complication rates. Success was defined as a lowering of IOP > 20% from baseline and IOP ≤ 14 mmHg. Complete success indicated that the target IOP was reached without medications.Six patients were included. The median IOP decreased from 35.5 mmHg (25.0–40.0 mmHg) at baseline to 11.5 mmHg , and median IOP-lowering medication was reduced from 4.0 (3.0–4.0) at baseline to 0  after two years. Five patients (83.0%) had a complete success after two years. Two patients (33.0%) required a needling procedure. Three patients (50.0%) required an intervention due to symptomatic hypotony within the first three weeks postoperatively. Hypotony resolved completely or was asymptomatic after three months.Our study demonstrated a statistically significant reduction in both IOP and number of IOP-lowering medications. Complications were well manageable and had no long-term sequelae. Recently, there has been increasing interest among glaucoma specialists in minimally invasive glaucoma surgery (MIGS).This is a prospective, nonrandomized, observational, consecutive case series pilot study at a single tertiary centre. The study was conducted in accordance with the tenets of the Declaration of Helsinki. All patients gave informed consent prior to surgery. Ethical approval was granted by the local institutional ethics committee of the University of Tuebingen, project-number: 719/2020BO2. All patients were treated with the new XEN63 gel stent between July and August 2020. Only patients with primary open-angle glaucoma, pigmentary glaucoma or pseudoexfoliative glaucoma with above target intraocular pressure (IOP) despite maximal tolerated IOP-lowering medication were included. We used the new XEN63 gel stent , which is identical to the model recently introduced into the market. It is composed of porcine gelatine crosslinked with glutaraldehyde. It is 6.0 mm long and has an outer and inner diameter of 170µm and 63µm, respectively. The injector has a 27G needle and is identical to the XEN45 gel stent injector.All surgeries were performed as solo procedure by a single experienced surgeon (B.V.) under topical anaesthesia as previously described.ab interno of a new XEN63 gel stent as described above. In this case, the conjunctiva was sutured with a 10–0 nylon suture and 10µg MMC (50µL) was injected at the site of the bleb at the end of the procedure.In one patient, the procedure was modified. This patient already had a XEN45 gel stent with a fibrotic non-functioning bleb. In this case, a revision of the bleb was attempted. During the preparation of the conjunctiva, the gel stent was damaged and was removed followed by the implantation Baseline IOP was assessed under IOP-lowering medication, which was then stopped two weeks before surgery. Oral acetazolamide twice daily was then given until the night before surgery. Unpreserved dexamethasone eye drops four times daily were started one week before surgery. No medication was given on the day of surgery. Postoperatively, antibiotic eye drops were given four times daily for a week and unpreserved steroids were tapered over 2 to 3 months. Patients were followed up on the first two postoperative days, as well as after 1, 3, 6, 12, 18 and 24 months after surgery.During follow-up, if IOP was not adequately controlled, then a needling procedure was performed instead of starting IOP-lowering medication. Needling was performed under topical anaesthesia. A 30G needle was bent and used to inject a small subconjunctival bubble of mepivacaine next to the XEN gel stent. Fibrotic tissue around the gel stent was then disrupted with sweeping movements of the needle tip. The stent was gently moved to assure free mobility of its tip. Then, 25µL of 0.2 mg/mL MMC (5µg) were injected in the filtering bleb. After surgery, moxifloxacin eye drops were started on the first postoperative day four times daily for three days and unpreserved dexamethasone eye drops were tapered over 1–2 months.p of less than 0.05 were considered to reflect significant differences.The statistical analysis was performed with the JMP 16.0 statistical package . Data are expressed as number (percentage), mean (standard deviation [SD]), mean , or median (range) as appropriate. We used the Wilcoxon signed-rank test to evaluate changes in the number of IOP-lowering medications and mean IOP. Values for The primary outcome of the study was the median change of IOP after two years. Secondary outcomes included changes in the number of IOP-lowering medications, complete success rate, needling rate and complications rate.Success of the procedure was defined as lowering of IOP > 20% from baseline and target IOP ≤ 14 mmHg. Complete success indicated that the target IOP was reached without IOP-lowering medication, whereas it was qualified in cases with or without IOP-lowering medication. Hypotony was defined as IOP < 6 mmHg.Any additional surgery other than needling procedures was classified as failure, as was loss of light perception. Combinations of IOP-lowering medications were counted as individual treatments.Demographic characteristics and clinical findings of the included patients are summarised in Median (range) age was 66 (54.0–84.0) years. Four patients (66.7%) were pseudophakic at the time of surgery. The median IOP decreased from 35.5 mmHg (25.0–40.0 mmHg) from baseline to 11.5 mmHg (4.0–15.0 mmHg) after two years  at baseline to 0 (0–1.0) after two years (p = 0.03). Complete success was reached in five of six patients (83.0%) after 2 years. The one patient who did not have a complete success had an IOP of 15mmHg on a single IOP-lowering medication after two years. The median change in visual acuity was −0.05 logMAR (−0.1–0.2) after two years (p = 1.0). None of the patients had a worsening of visual acuity greater than 0.1 logMAR or lost light perception. Two out of six patients (33.0%) required a single needling procedure because IOP increased over the target after four and six months, respectively.Four out of six patients (66.7%) had hypotony on the first and the second postoperative day. Two of those had an IOP > 6mmHg at the end of the second week. One patient developed hypotony at day two, which persisted until the end of the first month. Three patients required an intervention due to choroidal detachment and shallowing of the anterior chamber within the first three weeks after surgery. In these patients, the anterior chamber was filled with Healon5 OVD. Two patients required a second injection of Healon5 OVD after two and three days, respectively. Hypotony resolved in all but one patient after three months. In the one patient (16.7%) for whom it did not resolve in that time, the anterior chamber was normal, no choroidal detachment was present and the visual acuity recovered fully without further intervention.We did not observe any sight-threatening complications.Our study demonstrated a statistically significant reduction in both IOP and number of IOP-lowering medications after implantation of the new XEN63 in patients with open-angle glaucoma. Complete success was achieved in five of six (83.3%) patients after two years.Initially, the implantation device of XEN63 gel stent had a 25G needle and required a larger corneal incision compared to the current model.The XEN45 and XEN63 gel stents offer a theoretically derived outflow resistance of 6 to 8 mmHg and 2 to 3 mmHg, respectively, calculated with the Hagen-Poiseuille equation.18Interestingly, our complete success rate was even higher than that reported by Fea et al, although we used an amount of MMC that was at least four times lower (25µL of MMC 0.02% vs 100µL of MMC 0.02–0.03%).18In our study, two of our six patients (33.0%) required a single needling procedure. In contrast, Fae et al performed needling in four of 23 patients (17.4%).Interestingly, hypotony on day 1 was more common in our cohort than in the study by Fea et al (66.7% vs 17.4%) even though we used a smaller corneal incision for implantation (0.8 mm vs 1.8 mm) and a smaller amount of MMC (25µL of MMC 0.02% vs 100µL of MMC 0.02–0.03%).18Our study has several limitations. The number of patients is low, because of the restricted availability of the new XEN63 at the time this study was performed. Additionally, the oldest patient in our cohort was lost to follow-up one month after surgery, limiting the study population to six patients. Nevertheless, the remaining patients were meticulously followed up on over two years allowing us to gather valuable data on the new XEN63 gel stent.In conclusion, our study demonstrated a statistically significant reduction in both IOP and number of IOP-lowering medications after implantation of the new XEN63 gel stent in patients with open-angle glaucoma after two years. Complications were well manageable and had no long-term sequelae in this cohort.


Yarrowia lipolytica IPS 21 was tested for its ability to degrade potentially toxic chrome-tanned leather shavings (CTLS) in a liquid environment. Biological and chemical parameters were monitored during a 48-h period of biotransformation of the protein-rich waste. CTLS was added at a concentration of 0.1–4% (wt/wt) to a modified YPG medium (15 g L−1 yeast extract and 5 g L−1 NaCl). Biodegradation and bioconversion were performed in a one-step process. It was found that the higher degradation rate depended on the activity of the proteases and the pH of the medium, but not on the initial inoculum ratio and the activity of the dehydrogenase. The highest efficiency of the process was obtained for 4% (wt/wt) CTLS on day 2 . Our results showed that total chromium was probably not transported across the cytoplasmic membrane of Y. lipolytica IPS21 and that chromium (III) was not oxidized to chromium (VI). The phytotoxicity of selected amino acid supernatants [2.5% (vol/vol)] was tested after the bioconversion process. It was found that the supernatants had a stimulating effect on the plants tested. The root elongation was 29–28% higher than that of the reference samples. This result makes Y. lipolytica IPS21 a potential candidate for safely converting potentially toxic protein-rich wastes into valuable products without enzyme isolation, e.g., amino acid fertilizers.The yeast strain Yarrowia species or amino acids in various industries indicates the need for the extension of basic research on waste as a carbon source for this yeast. The experiments demonstrated that it is possible to use Y. lipolytica IPS21 for bioconversion of chrome-tanned leather shavings (CTLS) in a single-step process and to produce high-value amino acid supernatant without having an isolated enzyme. In our study, we show the effect of 2.5% (vol/vol) CTLS supernatant obtained from Y. lipolytica IPS21 on the elongation of the root system of selected plants and provide information on the effect of environmental factors on the efficiency of the bioconversion and the migration of chromium.Enzyme technologies have the greatest practical relevance to environmental trends. Overcoming the barrier of the high cost of carbon substrates used for biotransformation is the main challenge of these methods. The huge potential of the use of extracellular proteases of  Bacillus subtilis  on the ability of yeast to produce enzymes during degradation protein processes is also poorly understood . ChromiuY. lipolytica IPS21 to bioconvert different concentrations [0.1–4% (wt/wt)] of CTLS waste in a single-step process. Changes in dehydrogenase and protease activity, medium pH, degradation rate and biomass production, amino acid rate in the medium, and the total chromium and chromium (VI) content in supernatant and residues (biomass and CTLS residues) were determined. The stimulating effect of the supernatants (rich in amino acids) obtained after bioconversion on the plants was also tested using the Phytotoxkit microbiotest. Total nitrogen was measured.In this work, we have tested the ability of Y. lipolytica IPS21 yeast strain. This research is the first that uses Y. lipolytica IPS21 yeast to bioconvert CTLS in a single-step process and produce high-value amino acid supernatant without having an isolated enzyme. This is the first research that showed chromium migration (yeast biomass/liquid) during the 0.1–1% CTLS’s bioconversion process. This research is the earliest to use a high-quality amino acid supernatant from CTLS bioconversion by Yarrowia as a plant stimulant.The current study investigated the one-step degradation and bioconversion of pre-oxidised CTLS waste (sterilized at 121°C) using the Y. lipolytica IPS21 on biomass production and degradation of rate was estimated. Biomass production by tested yeast depended on the concentration of CTLS  CTLS was added. Microorganisms effectively utilized waste as a carbon and nitrogen source. The dynamics of biomass production were correlated with a higher concentration of CTLS  when the initial inoculum/concentration CTLS ratio was 2 [0.8 mL and 4% (wt/wt) CTLS]. Other samples had lower protease activity. Interesting results were obtained when casein was added. Proteolytic activity was higher with CTLS as an additional carbon source in some variants , which is 110.12 U mg−1 protein than with casein at 52.00 U mg−1 protein.Changes in protease activity are shown in −1 protein h−1 , probably as a result of CTLS degradation and related intermediates and biomass production. Significant differences in dehydrogenase activity were observed between samples with and without CTLS at 48 h of the process.Like the activity of yeast proteases, the activity of dehydrogenases in the first stage (24 h) was lower than in the second stage, from 12.6 to 28.05 µg TF mgtein h−1 . The higY. lipolytica IPS21 to the YPG-modified medium significantly increased the pH within 48 h of cultivation .The addition of 0.1–4% (wt/wt) CTLS and tivation . The pH Y. lipolytica IPS21 is shown in −1) were obtained at a concentration of 1% (wt/wt) of the CTLS. The lowest overall identified amino acid concentration was found in the control medium (244.57 mg L−1)  . The incY. lipolytica IPS21 affected total chromium in the liquid phase and biomass rate. The total chromium in liquid phase (supernatants) for a sample containing yeast and 1% CTLS was 42.24 g kg−1. As expected, this value was lower for the sample with only 0.1% CTLS (10.31 g kg−1). Chromium migrates to the supernatant as a result of the higher bioconversion of CTLS [1% (wt/wt)] by yeast. No chromium (VI) was detected in any of the samples  was variable . The resTable in .Yarrowia). Root elongation was 29% (Yarrowia and 0.1% CTLS) and 38% (Yarrowia and 1% CTLS) higher than distilled water  but also from hydrophobic substrates  (Y. lipolytica IPS21 was able to grow in the presence of CTLS waste as carbon source (Yarrowia probably caused the significant increase in medium pH (carbons) , 25. Y. n source . The degn source , proteasn source , and pH n source  were sign source –29, whn source . The pron source . Casein n source , 32. In n source . This man source  and thusn source . Biologin source . Changesn source . The intedium pH . The decedium pH .In our case, activity of proteases was a more important indicator than dehydrogenase activity. The activity of dehydrogenases differs statistically only in the presence of a higher concentration of waste and between the absence of waste and its low concentration. No changes were observed for 1% and 4% (wt/wt) of CTLS. The changes in dehydrogenase activity can occur as a result of stress caused by the presence of pollutants in environment , 36. DehY. lipolytica IPS21 may indicate an intensification of the degradation of waste. Waste can contain up to 90% collagen. High levels of amino acids are found in all CTLS supernatants. A yeast such as Yarrowia is characterized by a high content of many exogenous amino acids that build up the biomass  of the supernatant [2.5% (vol/vol)]. In these two treatments, the pH of the supernatant  content on plant growth promotion and to understand the exact mechanism by which they act on different soil types and different crops.This paper presents the effect of CTLS concentration on biological and chemical parameters during CTLS biotransformation into valuable products by Y. lipolytica IPS21 from the pure culture of the Łukasiewicz Research Network-Lodz Institute of Technology collection was maintained on “modified YPG” medium: yeast extract 15 g, sodium chloride 2.5 g, agar 25 g per liter of tap water, stocks at 4°C. Y. lipolytica strains have a high ability to produce proteases . The moisture content of the CTLS used in the process was 15% by weight. The pH of the demineralized aqueous solution (ratio 1:10) was 3.09. The CTLS was characterized by the following parameters: total ash of 8.6% ± 1.4, nitrogen of 16.5% ± 2.2, and chromium (III) oxide of 4.4% ± 0.2 according to the literature (Y. lipolytica IPS21 was tested for extracellular protease production by plating on skim milk agar plates containing peptone [0.1% (wt/vol)], NaCl [0.5% (wt/vol)], agar [2.0% (wt/vol)], and skim milk [10% (vol/vol)]. The microorganisms were incubated at 30°C for 48 h (Y. lipolytica IPS21 with proteolytic zone is at an average of 14 mm (n = 5).for 48 h . A changfor 48 h . Y. lipoY. lipolytica IPS21 was tested by plating microorganisms on agar-based growth media  with the addition of 100 mg CTLS or 300 mg CTLS. The tests were carried out (four replicates) according to the modified PN-EN ISO 20645 standard  was measured. The final OD 600 is 1,000. The stock suspension (0.4 or 0.8 mL) was added to 100-mL flasks containing 40 mL of sterile modified YPG liquid medium with CTLS of 0.1–4% (wt/wt). This was then incubated for 48 h at 30°C on an orbital shaker (190 rpm). The pH of the medium was adjusted to 7.07 prior to autoclaving at 121°C for 20 min.To prepare the The weight of dry yeast biomass was measured after filtering the cells under pressure on Whatman GC/F filters (100-mm diameter) and washing the cells with acetone and hexane (3:1) and sterile water by the gravimetric method. The samples were dried to constant weight at 80°C. The results are expressed in grams per liter. The degradation rate was calculated from the biomass concentration measurement.−1 NaOH. The ratio of supernatant to alkaline substance was 1 to 1. Absorbance at 440 nm was measured on a UV/visible spectrophotometer (Rayleigh UV-9200). One unit of proteolytic activity was defined as an increase of 0.01 in 40 min at A440 absorbance.Proteolytic activity was evaluated according to the literature , 50. TheDehydrogenase activity was determined according to the literature using 2,3,5-triphenyltetrazolium chloride (TTC) . In a fiThe change in pH was measured every 24 h using an Elmetron CP-411 pH meter. Five milliliters of post-culture liquid was taken for measurement.-1. The column flow was set to He 1.0 mL min−1. The injection temperature was set at 300°C. The transfer line to the mass spectrometer was maintained at 200°C. The MS was operated in scan mode (40–450 m/z) and SIM (selected ion monitoring).The determination of amino acids in the supernatants was performed by GC-MS. Samples of 0.1 mL were used for analysis. The samples were analyzed on a 2010 Plus GC chromatograph  equipped with the MS GCMS-QP2020 model. The GC column used was ZB-AAA . The temperature programme for the oven: an increase from 110°C to 320°C at a rate of 30°C min−1 were then used. Curve standards were prepared by diluting the stock solution. A buffer was used to eliminate matrix interferences spectrally, e.g., 10% lanthanum (III) nitrate in Pb and Cd analysis.The total chromium content in different types of liquid samples and biomass was determined by GFAAS using a Perkin-Elmer AA600 spectrometer . Total chromium was determined by GFAAS using a Perkin-Elmer AA600 spectrometer . To each sample, 0.1 g or 0.1 mL was added to 7 mL of 65% nitric acid (V). The mineralization process was carried out in three cycles for 20 min at 300°C and 45 bar pressure with maximum microwave power. The sample was then transferred to a 25-mL volumetric flask. Chromium standards (Chem-Lab) with an initial concentration of 1,000 mg LDetermination of chromium (VI) content in residues and supernatants after cultivation was performed in accordance with PN-EN ISO 17075-1:2017–05.Sorghum saccharatum , Lepidium sativum , and Sinapis alba  were used and incubated for 72 h at 25°C (±1°C). The response of the plants to the supernatants was determined by the degree of inhibition or stimulation of seed germination root growth. All measurements were made using the Image J analysis program. The total nitrogen content in each supernatant was determined after the process by the Kjeldahl method (Kjeltec System 1026).Phytotoxkit liquid sample is a 3-day germination and early growth test with seeds of three higher plants . All supernatant [2.5% (vol/vol)] variants were tested in the reference with foam pad, parafilm sheet, white filter paper, black filter paper, and seeds. Each variation was made in three replicates for each plant. Results are expressed as %inhibition or stimulation of root elongation  relative to distilled water. Mathematical and statistical analyses were performed using Statistica 10.0 . Differe


Open inguinal hernia repair is the most commonly performed procedure in general surgery in sub-Saharan Africa, but data on its learning curve are lacking. This study evaluated the learning curve characteristics to improve surgical training and enable scaling up hernia surgery in low- and middle-income countries.Logbook data of associate clinicians enrolled in a surgical training program in Sierra Leone were collected and their first 55 hernia surgeries following the Bassini technique (herniorrhaphies) were analyzed in cohorts of five cases. Studied variables were gradient of decline of operating time, variation in operating time, and length of stay (LOS). Eleven subsequent cohorts of each five herniorrhaphies were investigated.vs. 5.4 days, 95% 3.1–7.6). Operating times flattened after 31–35 cases which corresponded with 1.5 years of training.Seventy-five trainees enrolled in the training program between 2011 and 2020 were eligible for inclusion. Thirty-one (41.3%) performed the minimum of 55 herniorrhaphies, and had also complete personal logbook data. Mean operating times dropped from 79.6 (95% CI 75.3–84.0) to 48.6 (95% CI 44.3–52.9) minutes between the first and last cohort, while standard deviation in operating time nearly halved to 15.4 (95% CI 11.7–20.0) minutes, and LOS was shortened by 3 days (8.5 days, 95%CI 6.1–10.8 The learning curve of inguinal hernia surgery for associate clinicians flattens after 31–35 procedures. Training programs can be tailored based on this finding. The recorded learning curve may serve as a baseline for future training techniques.The online version contains supplementary material available at 10.1007/s00464-022-09726-5. To augment the global surgical workforce across all geographical regions and income groups, a rational redistributing of medical tasks between middle cadre health care workers, commonly called associate clinicians (ACs), and medical doctors (MDs) is recommended by the WHO , 2. ThisIn 2011 a postgraduate surgical training Program for ACs was initiated by the Sierra Leonean Ministry of Health and Sanitation (MoHS) and the non-governmental organization CapaCare . Sierra Knowledge on the pace of acquiring and mastering surgical skills among ACs is limited. In the context of medical education, learning curves based on serial evaluation of operation-specific outcomes are thought to provide insight about the progress of a trainee , 13. Whiad modem Bassini the dominant surgical technique in sub-Saharan Africa [Despite recommendations for open inguinal hernia repair to be enforced with a mesh –17, costn Africa –22. In Sn Africa .ad modem Bassini, performed by ACs within a task sharing surgical training program in Sierra Leone. To enhance surgical training and provide objective assessment parameters, the primary goal was to determine the number of inguinal hernia repairs that surgical trainees perform until flattening of operating time was observed. Secondary aims were to evaluate the variation in operating time, and length of hospitalization (LOS).The aim of this study was to evaluate the learning curve for non-mesh open inguinal hernia repair In this prospective cohort study, logbook data from ACs enrolled in a task sharing surgical training program in Sierra Leone were analyzed. The training curriculum was designed to enable ACs to safely manage the most common surgical and obstetric emergencies encountered at first level hospitals and is previously described in detail . Entry rTrainees enrolled in the surgical training between January 2011 and December 2019 were eligible for inclusion. Exclusion criteria were fewer than 55 logged open non-mesh procedures for inguinal hernia using Bassini technique   between subsequent cohorts with a power of 80 percent. The standardized difference was calculated by dividing the ‘difference to detect’ by the ‘standard deviation’ (SD). The estimated SD (20 min) was a derivative from learning curve studies by Miyazaki et al. and Harjai et al. both reporting on operating times of the Lichtenstein tension-free mesh inguinal hernia repair , 23. As Trainees kept record of operation specific data in paper-based logbooks and after each surgery, procedures were checked and signed by the supervising surgeon. The logbook data were transferred to excel and uploaded to an online server hosted by CapaCare and for this study transferred to protected servers hosted by Leiden University Medical Center, Leiden, The Netherlands. Data were checked for missing values and typing errors, and cleaned for duplicates. Logbook data from trainees was excluded from analysis, when ≥ 3 operating times among the first 55 herniorrhaphies were missing. All changes were logged.p-values < 0.05 were considered statistically significant.Changes in operating time and LOS between subsequent cohorts were compared using a linear mixed model analysis, with random intercept for trainee and a compound symmetry correlation matrix to account for the five different herniorrhaphies in each cohort from the same trainee. Changes in the variation in operating time, computed as the standard deviation of the operating time within each cohort for each trainee separately, were assessed using a linear mixed model as well, with random intercept for trainee. Differences in changes of operating time between trainees with ≥ 55 herniorrhaphies and those with < 55 herniorrhaphies were analyses using the linear mixed models as before, but with group and the two-way interaction between group and cohort added. Data are described by frequency and percentage for categorical variables, and by mean and standard deviation (SD) or median and interquartile range (IQR) for normally and non-normally distributed variables. To assess if the established learning curve was representative for all trainees, a sub-analysis was performed also including the trainees who left the training program prematurely due to insufficient progress, or for personal reasons and thereby failed to perform the required minimum of 55 herniorrhaphies. The sub-analysis on operating times was identically performed as for the group with ≥ 55 herniorrhaphies. All analyses were performed using SPSS statistics version 25 . All patient and trainee data were anonymized. All trainees consented to their anonymized logbook data to be used for research by CapaCare and affiliated researchers. The Masanga Medical Research Unit Scientific Review Committee (SRC-number: MMRU-SRC-007-2019) and the Sierra Leone Ethics and Scientific Review Committee (06/2019) granted approval.In total, 98 trainees enrolled in surgical training between January 2011 and December 2019, logging 54,980 operations, of which 12,030 (21.9%) were herniorrhaphies. On average, trainees observed a median of 2 (IQR 4) and assisted a median of 3 (IQR 4) herniorrhaphies before performing their first hernia procedure under supervision. All trainees enrolled after April 2018 were excluded from this study, as none had performed the required minimum of 55 herniorrhaphies by the 31st of December 2019. From the remaining 75 trainees eligible for inclusion, 31 (41.3%) had complete logbook data and performed each a minimum of 55 herniorrhaphies. Logbook data of 32 (42.7%) trainees that left or had to leave the surgical training program prematurely, or did not perform 55 herniorrhaphies for reasons not specified, were included for the sub-analysis on operating time  am/pm time errors were corrected, 30 (1.8%) operating times exceeded the set time boundaries and were removed, and 11 (0.6%) duplicates were removed. The majority of the included herniorrhaphies were planned procedures , performed under regional anesthesia  in a private hospital  with direct supervision . During the first two consecutive periods of 6 months in training, 393 (23.1%) and 452 (26.5%) herniorrhaphies were performed, respectively, corresponding to a mean of 12.7  herniorrhaphies per trainee during the first 6 months of training and 14.6  herniorrhaphies during the second 6 months of training. Most trainees had performed 55 herniorrhaphies by the second semester of the second year (Table p = 0.15) for the second cohort. In the subsequent cohorts, a further reduction in mean operating time was observed to 48.6 min (95% CI 44.3–52.9) for the eleventh slot. While a significant reduction in time was found between the third and fourth cohort , the decrease in time between cohort six and seven  was not significant (Table The mean herniorrhaphy operating time for the first five procedures was 79.6 min (95% CI 75.3–84.0), and declined to 75.8 min . This was not followed by a stabilizing mean time of surgery. Moreover, the evaluation on the trajectory of learning curve was significantly different, compared with trainees with more than 55 herniorrhaphies (p = 0.034)  but similar operating time of 47.5 min (95% CI 31.5–63.6) for the 11th cohort (Table p < 0.001). There were no statistically significant reductions in mean standard deviation observed between consecutive cohorts (Table The mean SD in operating time per cohort decreased from 26.6 (95% CI 22.8–30.3) to 15.4 (95% CI 11.7–20.0) minutes between the first and last cohort (p = 0.38)  herniorrhaphies. The mean LOS decreased from 8.5 (95% CI 6.1–10.8) days during the first cohort until 5.4 (95% CI 3.1–7.6) days for patients undergoing the 51–55 herniorrhaphy by the trainees. Despite a downward trend, the overall reduction in length of stay was not statistically significant Below is the link to the electronic supplementary material.


A short duration, palliative radiotherapy schedule for locally advanced and unresectable head and neck cancer (LAUHNC) was evaluated in terms of palliation of cancer-related symptoms and acute toxicities.The aim of the study was to compare the role and feasibility of hypo-fractionated radiotherapy with concurrent chemotherapy and hypo-fractionated radiotherapy in LAUHNC.All the patients included in this study of LAUHNC were not fit for curative treatment. These patients are assessed on the basis of quality of life (QOL), tumour response, toxicities, and relief in symptoms. QOL was assessed on the basis of University of Washington QOL questionnaire version 4 before and after treatment. Patients are divided into two arms, Arm A patients received 40 Gy in ten fractions concurrent cisplatin 50 mg/m2 with weekly and Arm B patients received 40 Gy in ten fractions. To assess the tumour response response evaluation criteria in solid tumours criteria were used.A total of 40 patients were enrolled in this study, with 20 patents in both arms. Three patients defaulted during treatment and one patient died during treatment. A total of 36 patients completed treatment. Before treatment common complaints was distressing pain in primary site, and difficulty in chewing and swallowing. After treatment there was reduction of pain and improvement in swallowing in both arms. Overall QOL improvement in Arm A (28.89 ± 18.44 to 46.67 ± 15.34) and in Arm B (31.11 ± 15.68 to 43.33 ± 15.72). Neither of the arms experienced grade IV mucositis and skin reaction.Toxicity in the form of mucositis and dermatitis was higher in the concurrent hypo-fractioned arm compared to the only hypo-fractionated radiotherapy arm during the treatment and in follow up period. The QOL in both individual arms showed statistically significant results, however when the QOL of both the arms was compared, the results were not statistically significant. In 2020, it was estimated that about 65,630 new cases of oral cavity, pharyngeal, and laryngeal cancer will occur which account for 3.6% of new cancer cases in the United States, as an estimated 14,500 deaths from head and neck cancers will occur during the same period of time [Patients often present with severe symptoms and there are no evidence-based guidelines for standard practice of palliative care in advanced head and neck cancer , 6. SurgIn this study, we assessed the quality of life (QOL) of locally advanced unresectable head and neck cancer using 2D RT with cobalt-60 machine before and after hypo-fractionated RT with or without use of chemotherapy, objective response to tumour and nodal site and comparing toxicities due to addition of chemotherapy.This prospective study was conducted on patients who reported to the RT department. All patients and family were informed about the stages of disease, prognosis, palliative intent and written consent was taken. Duration of the study was approximately 18 months starting from 2020 to 2022. All patients were at unresectable stage IV with no metastasis head and neck cancer and biopsy proven. In this prospective study, 40 patients were included and these patients were divided into two arms through the simple 1:1 randomization method. Patients who did not give consent for study and patients who had received prior definitive treatment in the form of RT or chemotherapy were excluded from the study.Distressing presenting symptoms like pain, painful ulcers, dysphagia, ondynophagia, breathing difficulty and neck swelling were recorded and graded according to the Washington QOL version 4.0 as per the patient’s reporting of the complaint. Dental evaluation was done prior to RT. Patients were also managed symptomatically according to their complaints.2 was given every Tuesday with the same RT protocol.All patients in Arm A received 40 Gy in ten fractions with two fractions per week (Tuesdays and Fridays). Patients were immobilized in the supine position. A primary and nodal gross tumour volume was outlined based on clinical examination. RT portal included gross tumour volume with 2 cm margin and the high risk nodal regions. The biologically effective dose for this regimen is 56 Gy for tumour tissue and 93.3 Gy for late reacting tissue. In the telecobalt machine (theratron Phoenix), RT was administered using the parallel opposed lateral approach [Patients were assessed weekly for assessment of treatment-related toxicity and tolerance. Treatment-related toxicity including radiation mucositis and dermatitis was assessed using the radiation therapy oncology group criteria . PatientTumour response and symptom relief were periodically monitored at 1 month intervals for 1 year and then 3 monthly or earlier if necessary. Patients with progressive disease were treated with symptomatic care and were initiated with injection methotrexate 50 mg weekly and tyrosine kinase inhibitor (Tablet Geftinib 250 mg once daily).t-test was used to evaluate the UW-QOL questionnaire. The paired t-test was used to evaluate the UW-QOL questionnaire. p < 0.05 was considered as statistically significant.The IBM SPSS Statistics 29.0 program was used to do the statistical analysis. Using descriptive statistics, patient demographic profiles, treatment variables, and radiation-induced toxicity were examined. The paired A total of 40 patients were included in the study out of which 3 defaulted and 1 patient died during treatment. Twenty nine patients completed treatment in 5 weeks and 7 patients completed their treatment in a median time of 7 weeks, during treatment 13 patients required nasogastric tube and 7 patients were prescribed opioid analgesic before and during treatment and 2 patients were prescribed to continue on opioid post-treatment for severe pain, the remaining patients had mild-to-moderate pain. Patients achieved a BED of 56 Gy to the tumour.The demographic profile is described in p-value < 0.0001, Arm B (63.33 ± 4.85 to 74.44 ± 7.05) p-value < 0.0001)) as depicted in Patients were assessed on the basis of the Karnofsky Performance Scale (KPS) before and 1 month after completion of treatment, there was significant improvement in both the arms before and after treatment (Arm A (63.89 ± 5.02 to 76.11 ± 6.08) p value < 0.001 Arm B (31.11 ± 15.68 to 43.33 ± 15.72) p value < 0.001)). There was significant improvement in pain, swallowing, appearance and activity but significantly the score decreased in taste, saliva, mood and anxiety in both the arms.Using UW-QOL questionnaire v4, the mean ± standard deviation before treatment and after 1 month of completion of treatment in both the arms, patients were assessed . In overAfter 1 month of completion of treatment an objective response assessment was done on both tumour and node. There was no complete response in either arm. Most patients presented with partial tumour and nodal response in both the arms. While 14 patients (77.8%) and 13 patients (72.2%) had partial response and 4 patients (22.2%) and 5 patients (27.8%) had stable response in Arm A and Arm B, respectively.p value = 0.5232).While after 1 month of follow up in both arms 1 (5.6%) patient had progressive nodal disease, 13 patients (72.2%) and 11 patients (61.1%) had partial nodal response and 4 patients (22.2%) and 6 patients (33.3%) had stable disease, respectively. As shown in The main aim of this study was palliation of distressing symptoms like painful ulcers, pain, difficulty in swallowing and to study treatment-related toxicities and QOL. In our study, improvement in QOL and cost benefit issue are important because our patients belonged to a lower socioeconomic status and came to us beyond the incurable stage. Radical treatment in the form of an aggressive multi-modality approach is not successful in all of these patients because of poor performance status and unresectability. These advanced and unresectable cases need palliative treatment and/or best supportive care.et al [A similar RT regimen like the one in this study was investigated by Mudgal et al . Grade Iet al [et al [The toxicity profile with concurrent carboplatin given with hypo-fractionated accelerated RT was shown by Madhava et al  Grade 3 l [et al  in his sAt the end of the complete treatment, in Arm A 13 patients had grade II mucositis and 5 had grade III mucositis. Whereas in Arm B 16 patients had grade II mucositis, 2 had grade III mucositis.After 1 month of follow up mucositis decreased in both the arms but decreased more in the hypo-fractionated RT arm compared to the concurrent hypo-fractionated RT arm. Neither arm had any grade III or IV mucositis. One month after treatment completion, in Arm B all patients had grade I mucositis or no mucositis. However, in Arm A three patients did show grade II mucosal toxicity.In Arm A and B, during RT dermatitis increased due to high dose per fraction, after completion of 5# neither arm has grade III and IV dermal toxicity. After completion of treatment 10 # Arm A dermal toxicity was slightly more compared to Arm B, two patients experienced grade III toxicity in Arm A but no patients reported grade III toxicity in Arm A. After 1 month follow up hyper pigmentation seen in both arms, 11 and 13 patients reported no toxicity and 7 and 5 patients reported grade I dermal toxicity in Arm A and B, respectively.et al [Porceddua et al  ‘Hypo Tret al [p = 0.03), but no significant change was observed in head and neck specific score  after treatment. Reduction of pain was observed in 88% patients and 60% patients had improvement of performance status.Das et al  conducteet al [In 2019, Mudgal It is known till now that no studies have been conducted on QOL improvement in concurrent hypo-fractionated palliative RT.p = 0.002*) and in Arm B, 38.89 ± 17.62 to 51.39 ± 13.48 pre-treatment and post-treatment (p = 0.006*) but when compared to Arm A the Arm B result was insignificant (p = 0.5309). In Arm A swallowing improved from 33.00 ± 19.60 to 44.00 ± 19.60 pre-treatment and post-treatment (p = 0.111) and in Arm B swallowing improved from 14.71 ± 23.48 to 26.47 ± 25.72 (p = 0.041*) and when compared to Arm A, Arm B result was statically significant. In overall QOL, there was significant improvement in both the arms (Arm A (28.89 ± 18.44 to 46.67 ± 15.34) p value <0.001 Arm B (31.11 ± 15.68 to 43.33 ± 15.72) p value < 0.001)) but when compared Arm A and Arm B side by side the result was insignificant (p = 0.4714). There was significant improvement in pain, swallowing, appearance and activity but significantly the score decreased in taste, saliva, mood and anxiety in both the arms.In the present study, the main presenting complaints of patients were pain and dysphagia, 70% of patients presented with two or more distressing symptoms. Using UW-QOL questionnaire v4, the mean ± standard deviation before treatment and after 1 month of completion of treatment in both the arms, patients were assessed. There was pain relief in Arm A from 37.5 ± 19.65 to 54.17 ± 12.86 pre-treatment and post-treatment  and 13 patients (72.2%) has partial response and 4 patients (22.2%) and 5 patients (27.8%) has stable response in Arm A and Arm B, respectively. While after 1 month of follow up in both arms 1 (5.6%) patient has progressive nodal disease, 13 patients (72.2%) and 11 patients (61.1%) has partial nodal response and 4 patients (22.2%) and 6 patients (33.3%) has stable disease, respectively. .In the present study, hypo-fractionated palliative RT showed promising results in LAHNC in both the arms with high dose rate at tumour site, good symptomatic relief and minimal toxicity. However, the addition of concurrent chemotherapy to the hypo-fractionated regimen showed a higher rate of mucositis and dermatitis and similar QOL profile, but conferred no statistically significant advantage in terms of tumour response. The limitation of this current study is a shorter follow-up period and small sample size.CFRT: Conventional fractionation radiotherapy; CTRT: Concurrent chemo radiotherapy; KPS: Karnofsky Performance Scale; LAUHNC: Locally advanced and unresectable head and neck cancer; SCC: Squamous cell carcinoma; UW-QOL: University of Washington quality of life questionnaire.The author(s) declare that they have no conflict of interest either financial or non-financial.No direct or indirect funding was received for this clinical work.SNMC/IEC/THESIS/2022/144.


Risk evaluation is a global process covering different aspects of employee’s workandfamily life. Nowadays, psychosocial risks are as important as physical and chemical risks, and their identification isdeterminant in each workplace.Our study aimed to assess psychosocial risks among Electricity and Gas Company’s employees and to identify factors related to these risks.A cross sectional study was conducted among male workers in a Tunisian electricity and gas Company. The KRASEK scale was used to assess psychosocial risks. The Statistical analysis was performed with SPSS version 23.Among male workers in the company, 83 employees participated in this study. The mean age of our population was 41.28 years± 12.12 years. Manuel labour was identified in 67.5% of cases. High psychological demands were reported by 63.9% of the employees. The assessment of decision latitude dimension identified low autonomy at work in 54.2% of cases. The mean social support scale was 23.73± 4.18. Job strain was identified among 32.5% of participants. Among employees in job strain, twenty-one subjects (77.8%) were affected in the technical division and 21.7% were in “iso strain”. Job strain and iso strain were associated with sedentary workers aged less than 45 years, p values were 0.006  and 0.010  respectively. However, Iso strain was negatively associated with being married (p=0.038) (0.0327 IC 95% [0.111-0.964]).This study highlighted the importance of psychosocial risks in this company. The identification of these risks in the workplace may further help preventers to recommend proper interventions to offer employees a supportive work environment and to enhance their personal and professional well-being.None Declared


India is witnessing an epidemic of type 2 diabetes. Overweight/obesity, overnutrition, physical inactivity, and family history are well-known risk factors for diabetes. We investigated the role of undernutrition in the development of diabetes among rural adolescent girls.1C) and body size using anthropometry and body composition using bioimpedance. Prediabetes was diagnosed using the American Diabetic Association (ADA) criteria. We also calculated various HOMA indices for insulin resistance (HOMA-IR), β-cell function (HOMA-β), insulin sensitivity (HOMA-S), and compensatory β-cell response using a homeostasis model. BMI, body fat%, and waist circumferences were treated as exposures and all the glycemic parameters and indices as outcomes.DERVAN cohort study was set up in the KONKAN region of the western Indian state of Maharashtra. It enrolled 1,520 adolescent girls (16–18 years old at the time of enrollment). We measured glycemic parameters  was observed in 5.7%. The prevalence of prediabetes was 39.4%. Fasting insulin concentrations, HOMA-IR, and HOMA-β showed a positive trend across body composition quartiles (p < 0.001). HOMA-S and compensatory β-cell response showed an inverse trend (p < 0.001). Compared with prediabetic girls in the overweight/obese group, girls most undernourished group had lower median insulin concentrations (8.1 μIU/ml vs. 17.1 μIU/ml), lower HOMA-IR (1.1 vs. 2.3), and lower HOMA-β (75.6 vs. 129.2) but higher sensitivity (87.4 vs. 43.7) (p < 0.001) for all.The median age of the subjects was 16.6 years. The median weight, height, and BMI were 40.7 kg, 151.7 cm, and 17.5 kg/mWe have reported a high prevalence of prediabetes among rural adolescent girls with a very low prevalence of obesity. Prediabetes in obesity is driven by hyperinsulinemia and overworking of the pancreas while poor β-cell function and poor insulin secretion are major drivers in the undernourished group. The high-risk diabetes screening programs are much needed for the undernourished populations. Caution should be exercised for planning the interventions as overfeeding (or overnutrition) is likely to put the populations at risk of development of obesity and insulin resistance. Diabetes is a global public health problem with an evident burden in developing countries such as India . This phUndernutrition has been prevalent for many generations in the KONKAN region of the western Indian state of Maharashtra , but at 1C was measured using high-performance liquid chromatography  calibrated against the National Glycosylated Standardization Program with a coefficient of variation (CV) of 2.8%. Blood samples were centrifuged  within 1 h of collection and stored at −80°C for further investigations. Blood glucose was measured on ERBA 200 with the intra- and interbatch CVs of <5%. Fasting insulin was measured on Abbott Architect i1000SR with a CV of 2.0%.Adolescent girls were brought to the institute for residential camp in groups of five to seven to ensure overnight fasting. Many of them were also accompanied by their parents. Fasting and 2-h postprandial blood samples were obtained from the girls the next morning. Random blood samples were obtained from the accompanying parent. HbAHeight, weight, and circumferences  were measured using standardized protocols. Body composition was measured using a bioimpedance MC-780 analyzer .1C was defined as HbA1C of ≥5.7% and <6.5%. We used American Diabetic Association (ADA) /100 (th percentile for waist circumference (Impaired fasting glucose (IFG) was defined as fasting glucose of ≥100 mg/dl and <126 mg/dl. Elevated HbAon (ADA)  criteriadiabetic . Normal diabetic . We estiA-β)/100 . UnderweA-β)/100 . ThinnesA-β)/100 . AdiposiA-β)/100  and centmference . Parentsth-75th percentile). Categorical variables are represented by frequency and percentage. For statistical analysis, body composition parameters  were treated as exposures. Glycemic parameters, indices and PD were treated as outcomes. We created quartiles of exposures. We further divided fourth quartile of each exposure into two groups  thus eventually creating the 5 groups of each of the exposures. Group 1 and group 5 represented lower and higher extremes of each of the exposure. Anthropometry, glycemic parameters, HOMA indices and PD prevalence were compared across the five groups of each exposure using linear regression or logistic regression as appropriate. Interaction (2 way and 3 way) between body composition exposures  for outcomes (fasting glucose/PD) were tested by including appropriate product terms in linear or logistic regression. Comparison between groups was performed using the t-test/ANOVA/Kruskal–Wallis test/chi-square test as appropriate. Statistical software SPSS V25.0 and STATA 13.0 were used for the analysis.Each variable was tested for normality using the Kolmogorov–Smirnov test. Those found not normal were appropriately transformed. The data are represented by median  is registered with the Department of Health Research (DHR) Government of India. Appropriate written informed consent was obtained from the adolescent girls who were 18 years old at the time of recruitment. For those below 18 years of age, written informed consent was obtained from the parents and written informed assent was obtained from the adolescent girl. Additional consent was also obtained from parents for their own blood and clinical investigations.n = 5) were excluded. Thus, our analysis was performed on a sample of 1,395 girls.We enrolled 1,520 adolescent girls between June 2019 and February 2023. Body composition measurements were taken for 1,400 subjects. Those diagnosed with diabetes  of the adolescent girls are shown in 2 respectively. Using the WHO classification, 28.8% were classified as underweight and 30.4% were stunted. Thinness and overweight/obese using the IOTF standards were observed in 58.4% and 4.2% respectively. The median waist circumference, hip circumference and waist-to-hip ratio were 62.1 cm, 83.2 cm and 0.751 respectively. Only 1.7% of the girls were centrally obese.The median age at enrollment was 16.6 years. The median weight, height and BMI were 40.7 kg, 151.7 cm and 17.5 kg/mThe median lean mass and fat mass were 29.5 kg and 8.8 kg respectively. The median body fat% was 22.5 and 5.7% of the girls had body fat% of >35.1C and insulin concentrations were 95.4 mg/dl, 5.3% and 8.6 μIU/ml respectively. IFG was diagnosed in 31.0% and elevated HbA1C in 13.8%. A total of 39.4% of the girls had PD. The median values for various glycemic indices calculated using the homeostasis model were 1.2 for HOMA-IR, 94.5 for HOMA-β, 86.1 for HOMA-S and 79.6 for compensatory β-cell response. We were able to collect postprandial blood samples only in 1,226 girls. Median postprandial glucose concentration was 102.0 mg/dl and only 15 (1.2%) had postprandial hyperglycemia. Out of these 11 were IFG.The median fasting glucose, HbAParents  of 547 adolescent girls reported to the institute for blood investigations; 7 fathers and 14 mothers were known diabetic and 4 fathers and 5 mothers were newly diagnosed with diabetes.p = 0.041). All the remaining parameters were similar.1C and the proportion of those with PD were similar across the five groups. Fasting insulin concentrations, HOMA-IR and HOMA-β showed a positive trend across the BMI groups . HOMA-S and compensatory β-cell response showed an inverse trend (p < 0.001 for both). Similar results were obtained when we used other exposures such as body fat%   when compared to girls with PD in the overweight/obese group had significantly lower insulin concentrations (8.1 μIU/ml vs. 17.0 μIU/ml), lower insulin resistance (1.1 vs. 2.3), lower β-cell function (75.6 vs. 129.2) but higher sensitivity (87.4 vs. 43.7)  . Similarfor all)  and waisfor all) .Using continuous data, there was no statistically significant 2-way interaction between BMI and body fat%, BMI and waist circumference and body fat% and waist circumference for fasting glucose concentrations. The three-way interaction between BMI, body fat% and waist circumference was also not significant. Using a categorical approach, there were no statistically significant interactions (2 way or 3 way) for PD.1C of >5.8% cutoff was used for diagnosis. We used ADA criteria as it has been shown to improve the parity between IFG and IGT , adiposity (using body fat%) and central obesity (using waist circumference) was very low. The proportion of girls with PD was 39.4% and postprandial hyperglycemia was observed only in 1.2%. Prediabetes has been characterized by the simultaneous presence of insulin resistance and β-cell dysfunction abnormalities that start before glucose changes are detectable . Accordi and IGT .Girls in our cohort are undernourished, yet have a high prevalence of PD. In most of the studies on PD in adolescents, the subjects were either overweight or obese. Our study is being carried out in a region witnessing undernutrition from birth to adolescence  as well β-cell secretory capacity and age-related insulin insensitivity were identified as causes of glucose intolerance among young adults in a longitudinal cohort study . Our stuStudies report a conversion rate from PD to diabetes of ~5–10%, which varies in different populations and by definition of PD –38. SeveData were collected at the recruitment stage of the cohort, where measurement of glucose was taken only once. Only when we have glucose measurements at subsequent follow-ups, we will be able to study the evolution of glucose tolerance.There are some limitations in our study. We did not do the oral glucose tolerance test (OGTT); hence, we could not assess IGT and first-phase insulin secretion in our girls. Our study sample consists only of girls; hence, we cannot generalize our findings.To summarize, the subjects in our analysis sample are younger and non-diabetic but still have a high prevalence of PD with poor insulin levels. High-risk screening programs for diabetes should also concentrate on the undernourished populations. Caution should be exercised for planning the interventions to restore insulin sensitivity. Overfeeding only macronutrients is likely to put the populations at risk of developing insulin resistance leading to T2D in future. Only systematic follow-up of our cohort will tell us about the causality of diabetes in the undernourished.dr.suvrnanpatil@gmail.com.The datasets presented in this article are not readily available because the datasets generated are available from the corresponding author on reasonable request with necessary permissions from Institutional Ethics Committee and Government of India HMSC permission. Requests to access the datasets should be directed to SP, The studies involving human participants were reviewed and approved by our Institute Ethics Committee (EC/755/INST/MH/2015/RR-18) is registered with the Department of Health Research (DHR) Government of India. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.SP is the principal investigator of the study and wrote the first draft and discussion section. NP and PH-B helped in literature review, writing of the manuscript, and carried out laboratory assays. OD managed and analyzed the data. ANa carried out laboratory assays. AY and ANi also helped in the interpretation of laboratory data. CJ carried out literature review, results interpretation, writing of manuscript, and also helped in discussion. RB participated in laboratory assays and final editing. All authors contributed to the article and approved the submitted version.


To evaluate the alternate use of flash glucose monitoring (FGM) with self-monitoring blood glucose (SMBG), in patients with type 1 diabetes (T1D).Two weeks of open FGM (P2), both preceded (P1) and followed by 2 weeks (P3) of SMBG with a blinded FGM system. Mean absolute relative difference (MARD) was calculated by (|FGMi − SMBGi|) / SMBGi, where it was a paired data sample.p = 0.005), increased % time spent in hyperglycemia (>180 mg/dL)  with no significant change in % TIR. The proportion of patients who reached sensor-estimated glycated hemoglobin (eA1c) < 7% decreased from 23.5% at P1 to 12.9% at P2, p = 0.028. For the whole sample, the MARD between the two methods was 15.5% (95% CI 14.5-16.6%). For normal glucose range, hyperglycemic levels and hypoglycemic levels MARD were 16.0% (95% CI 15.0-17.0%), 13.3% (95% CI 11.5-15.2%) and 23.4% [95% CI 20.5-26.3%)], respectively.In total, 34 patients were evaluated. Time in range (TIR) did not change between P1 and P2. In 12 patients (35.3%), TIR increased from 40% at P1 to 52% at P2 (p = 0.002) and in 22 (64.7%), TIR decreased or did not change. FGM use resulted in decreased % time spent in hypoglycemia (<70 mg/dL) (6.5% vs. 5.0%; FGM after usual SMBG decreased the % time spent in hypoglycemia concomitant with an undesired increase in % time spent in hyperglycemia. Lower accuracy of FGM regarding hypoglycemia levels could result in overcorrection of hypoglycemia. Type 1 diabetes (T1D) is a chronic disease that requires individualized therapeutic intervention associated with self-management tools, such as regular and constant glucose monitoring. However, achieving ideal glycemic and metabolic control to minimize micro- and macrovascular complications remains a major challenge, especially for patients on complex insulin therapy regimens. According to the results from the BRAZDIAB study, a Brazilian multicenter study carried out in the public health system including 3,466 patients with T1D, only 13.2% of adults and 23.2% of children met the goal for glycated hemoglobin (A1c) , A1c levels are considered the best parameter for assessing glycemic control and the incidence of diabetes-related chronic micro- and macrovascular complications . HoweverNew methods for monitoring glucose include detecting glucose in the interstitial fluid through a continuous glucose monitoring (CGM) or flash glucose monitoring (FGM) system, in parallel with traditional ambulatory self-monitoring of blood glucose (SMBG). The FGM system has emerged recently as a useful, practical, and well-proven tool in randomized clinical trials for intermittent and real-time blood glucose monitoring ,7. ThereThe FGM system has been proved in the Al Hayek's prospective study to improve clinical parameters once the patients had been switched from the fingerprick method to FGM over 12 weeks in children and teenagers with T1D . MoreoveThe primary aim of this study was to evaluate the clinical impact of the alternate use of FGM with SMBG in patients with T1D in a public healthcare unit in Rio de Janeiro, Brazil. Also, we aimed to identify the characteristics of patients who benefited the most from using FGM in terms of improvements to TIR.This prospective cohort study was conducted at the Diabetes Outpatient Clinic of the State University of Rio de Janeiro between May 2019 and September 2020. The inclusion criteria were T1D patients older than 4 years, regular follow-up at the outpatient clinic, and stable insulin regimen for at least 3 months. T1D was clinically defined according to the American Diabetes Association criteria . The excCertificado de Apresentação para Apreciação Ética” certified at Plataforma Brasil was 07626319.0.0000.5259. Written informed consent for the study was obtained from all of the patients aged 18 years or older, and from the parents or guardians of the patients younger than 18 years old.The study was approved by local center's ethics committee and CAEE “2). Economic status was defined by the Brazilian Economic Classification Criteria , weight (kg), insulin dose (IU/kg), type of insulin , SMBG frequency, blood pressure, and heart rate. Body mass index (BMI) was determined by dividing weight (kg) by the square of height  using the Boronate method with the Alere Afinion HbA1c AS100 Analyzer equipment kit, which provides results after 3 minutes (VR = 4.0 to 15%). This method has been validated and meets all National Glycohemoglobin Standardization Program (NGSP) A1c performance criteria.  is a glucose reader that allows intermittent glucose monitoring in the interstitial fluid through a sensor applied under the skin, which lasts 14 days. Each patient's glucose monitoring was assessed for a continuous period of 2 months (4 sensors). The participants attended the Diabetes Clinic every 14 days to change the sensor and upload data to a computer. The collected data were sent retroactively to the health professional who assisted the patient, and the information on glycemic variability, time in range (TIR), percentage of time in hypoglycemia and hyperglycemia, and frequency of hypoglycemia were analyzed. First, the patients had a 14-day run-in period for the FGM, for adaptation and instruction. This was important because no patient had used it before. Those who did not adapt to the run-in period could not continue in the study. Afterward, the first period started (P1), during which we masked the sensor by placing adhesive tape over the reader display and instructed the patients to scan 8 times/day at the same time when they used SMBG, even without seeing the results, to capture all the baseline parameters provided by the FGM during the usual care on SMBG. During this blind period, patients were instructed to adjust their insulin therapy according to SMBG, performed 8 times/day .The second period (P2) was designed to evaluate if FGM, as compared to the intermittent results of SMBG, could affect the patients’ behavior and attitudes as well as their management of insulin doses. Afterward, in the third period (P3), we repeated the masked use of the sensor to evaluate if the impact of previous FGM use was sustained after interruption and return to usual SMBG, possibly allowing for intermittent use of the FGM .The FGM parameters analyzed were percentage of FGM use (defined as the percentage of time FGM was active and recommended > 70% of data from a period of 14 days), sensor-estimated A1c , TIR (70-180 mg/dL), and percentage of time in different glycemic ranges: level 2 hypoglycemia <55 mg/dL), level 1 hypoglycemia (<70 mg/dL), level 1 hyperglycemia (>180 mg/dL) and level 2 hyperglycemia (>250 mg/dL) , sensor-estimated A1c , TIR (70-180 mg/dL), and percentage of time in different glycemic ranges: level 2 hypoglycemia <55 mg/dL), level 1 hypoglycemia (<70 mg/dL), level 1 hyperglycemia (>180 mg/dL) and level 2 hyperglycemia (>250 mg/dL)  or as median [interquartile range (IQR)] for continuous variables and as numbers (relative frequencies) for discrete variables. The numeric variables were compared using parametric and non-parametric tests, either paired or not, as appropriate. The chi-square and Fisher tests were used to compare the frequencies of the categorical variables. The statistical analyses were performed with Statistical Package for Social Sciences (SPSS) for Windows . A two-sided The accuracy of FGM was evaluated using the mean absolute relative difference (MARD), a variable calculated as the difference between the interstitial glucose values obtained from FGM and blood glucose, as measured with the usual SMBG, at the same time. MARD is given by (|FGMi − SMBGi|) / SMBGi, where it is a paired data sample. The MARD results are presented with 95% CIs, calculated considering a Student's t-distribution. Pearson's correlation coefficient was used to evaluate the relationship between FGM and SMGB. An ordinary least squares regression was deployed to calculate the function for associating the FGM measurement with the expected SMBG measurement. The regression coefficients help to show where a dependent relationship exists between FGM and SMBG . For graWe enrolled 39 participants between May 2019 and August 2020. Of these participants, five (12.8%) were excluded before completing the study . Five sensors stopped working before 14 days (mean of 10 days use). Two children felt pain upon the sensor's insertion. Six participants presented bleeding at the site of the sensor's insertion. We replaced 19 total sensors over the time of the study.p = 0.05).The baseline characteristics of the studied population are shown in The mean FGM use for each 14-day period was 90.7%, 92.1%, 93.0% and 92.5%, respectively.The mean number of sensor scans per day was 7.1 ± 2.1 for P1 and 9.6 ± 3.4 for P2.p = 0.002) and in 22 (64.7%), TIR decreased or did not change , lower total daily insulin at baseline , and lower A1c at baseline , when compared to those patients that did not improve, respectively. No difference was found in ethnicity, physical exercise practice, current age, diabetes duration, age at diagnosis, baseline SMBG frequency, type of basal or bolus insulin, difference between insulin dose (IU/kg) from P2 to P1, economic status and number of scans in P2.Overall, TIR did not change between P1 and P2 . In 12 pt change . The facp = 0.028 (The proportion of patients who reached eA1c < 7% decreased from 23.5% at P1 (SMBG effect) to 12.9% at P2 (FGM effect),  = 0.028 .p = 0.005). (p = 0.006) (The percentage of time spent in level 1 hypoglycemia (<70 mg/dL) decreased from 6.5 [1.0-4.0]% at P1 to 5.0 [2.0-10.0]% at P2 ( 0.005). . The pro= 0.006) .vs. 6 [3.5-11]%, p = 0.035). No difference was observed during P1 or P2 in the percentage of time in hypoglycemia < 70 mg/dL, regarding type of basal insulin used .Percentage of time spent in hypoglycemia showed no association with insulin dose . Patients who used regular human insulin presented higher percentages of time with hypoglycemia < 70 mg/dL in P1, but not in P2, than those on rapid-acting insulin analogs did (13 [6-19.5] % p = 0.046), and the number of patients who reached less than 25% of time spent on level 1 hyperglycemia decreased from 5 (14.7%) at P1 to 2 (6.5%) at P2 (p = 0.013) (The percentage of time spent in hyperglycemia level 1 increased from 44.5 [35.0-54.3] % at P1 to 51 [41.0-64.0] % at P2 (= 0.013) . In 10 pp = 0.02). No significant change occurred in total insulin dose (p = 0.08) or in daily insulin bolus (p = 0.27) from P1 to P2 . Fewer patients reached the goal of percentage of time spent in hypoglycemia level 1 < 4%  and more patients reached the eA1c target of < 7% . No association existed between percentage of time spent in hypoglycemia in P2 or P3 and insulin dose  or type. No statistically significant difference was observed in the other glycemic control parameters.After the transition from P2 to P3, the percentage of time spent in hypoglycemia level 1 increased (8 [4-13]% p < 0.001) (p = 0.026). Regression coefficients for the entire sample, TIR and hyperglycemia levels were 0.87, 0.82, and 0.75, respectively, with a small 97.5% CI span . For all of the measurements over 14 days, FGM had an adequate correlation with SMBG  . For the CI span , showingThe Clarke error grid  showed tIn the present study, short-term use of FGM after usual SMBG revealed that TIR decreased or did not change in the majority of patients and revealed a decreased percentage of time spent in hypoglycemia concomitant with an increased time spent in hyperglycemia but not TIR, as desired. We also showed lower concordance of the FGM with the hypoglycemia level compared to SMBG. To our knowledge, this is the first study to evaluate the clinical impact of FGM among adults and pediatric patients with T1D in a Brazilian public tertiary diabetes center.The use of a blinded FGM made it possible to discover that patients used to spend long periods in previously undetected hypoglycemia. As expected, FGM use lowered the percentage of time spent in hypoglycemia, in agreement with the findings from the IMPACT study, in which 358 patients with T1D were randomized to either the FGM group or the control group (SMBG) for 6 months, also resulting in a decreased percentage of time spent in hypoglycemia at the end of study in the FGM arm ,17.This study was not intended to directly assess FGM's performance when compared to SMBG because the accuracy of FGM has already been described elsewhere ,18. RathOur results are similar to those found by Battelino and cols., who demonstrated that FGM use reduced time spent in hypoglycemia, in parallel to an increase in time spent in hyperglycemia (>180 mg/dL). However, differently from us, they observed increased TIR . These dTIR remained almost the same throughout the study. However, we identified that in 36% of patients, mostly males with lower baseline A1c levels and using lower insulin doses, TIR increased during FGM use, as compared with SMBG. These results are supported by the findings of a long-term study including 347 children and adolescents that showed a better glycemic outcome in only 35% of patients, after 1 year using FGM . In addiWe observed a 0.2% decrease in A1c levels from baseline to the end of our study. This was similar to the study conducted by Campbell and cols. , which fAdverse sensor-wear events were mild and tolerated, but they impacted the number of sensors used throughout the study. Early sensor detachment was the largest barrier of our study, especially in children. This finding was also the most encountered inconvenience in a study with 67 children . MoreoveThe strength of this study was that it included real-world data from a Brazilian tertiary public center. We chose to include patients with T1D, regardless of their glycemic control, gender, age, or insulin treatment regimen.Finally, we must address some limitations. These include the short duration of the study, the relatively few participants in each age group , and the lack of a control group with which to compare our results.In conclusion, FGM use after usual SMBG revealed that in the majority of patients TIR decreased or did not change and revealed a decreased percentage of time spent in hypoglycemia concomitant with an increased time spent in hyperglycemia. Male gender, lower total insulin dose, and lower A1c at baseline were the factors associated with improved TIR in a subgroup of patients. The lower accuracy of FGM at lower glucose levels could have clinical effects in overcorrection of hypoglycemia. Further studies over a longer period are needed to assess whether patients would manage hypoglycemia events better with the help of FGM.


This study was using Cone beam computed tomography (CBCT) to examine the anatomical variations in mandibular second molars in an Egyptian sub-population.p < 0.05). Data were presented as frequency and percentage values and were analyzed using chi square test followed by pairwise comparisons utilizing multiple Fisher’s exact tests with Bonferroni correction. The significance level was set at p < 0.05 within all tests.A total of 350 CBCT images  of mandibular second molars were evaluated. Samples were evaluated in terms of: number of roots, number of root canals, roots’ cross section as well as prevalence and configurations of C-shaped canals. Statistical analysis was done to highlight differences between different categories and their prevalence among genders (significance level was set at p = 0.656). Most samples had three root canals (80%) followed by two (16%), then one (3.2%), and finally four (0.8%) root canals. Among the non-C-shaped molars, presence of two roots was most common (83.4%) followed by presence of a single root (16.2%), and only one sample (0.2%) had three roots, and this had no correlation with gender . In the mesial roots Type IV Vertucci was the most common configuration found (68.8%), while Type I was the most prevalent in the distal roots (91.8%). The long oval configuration was the most commonly found cross section in mesial roots while “oval” was the most prevalent in distal roots.Of the 350 mandibular second molars evaluated, 87.2% were non-C-shaped while 12.8% were C-shaped with no gender-based statistically significant differences (χ2 = 0.19, Egyptian sub-population shows highly variable morphological features in mandibular second molars, hence, CBCT is highly recommended on case-to-case conditions. Sufficient knowledge on root canal morphology is essential for recognizing and treating anatomical details within the root canal system. Root canal systems show wide variations that include the presence of extra roots, extra root canals, fins, isthmuses loops, as well as unique morphologies such as S-shaped and C-shaped canals , 2. SuchMandibular second molars are amongst the teeth that exhibit a wide variation in their internal and external anatomy according to race and geographic origin –14. A chDifferent methodologies evolved throughout decades to study the morphology of root canal systems . One of To date, there is scarce knowledge about the morphology of mandibular second molars in the Egyptian population. This study aimed to investigate the number of roots, root canal configurations, prevalence and morphology of the C-shaped root canal system in mandibular second molars within an Egyptian subpopulation using high- resolution CBCT.A power analysis was performed using G*Power version 3.1.9.7.  based on the results of Senan et al. , the preThis study was approved and the need for consent to participate was waived by the Research Ethics Committee of The British University  (22–007) given the type of the retrospective study and given that the CBCT images included were anonymous. Random CBCT images for 350 patients who required a preoperative 3D radiographic assessment between January 2021 and December 2021 were collected from a private maxillofacial imaging center and included in the study. The patients were referred to the imaging center for preoperative assessment as part of their dental examination, diagnosis, and treatment planning; this included orthodontic, periodontal and surgical reasons.n = 350) was reached after examination of a total of 470 CBCT scans. The excluded scans  did not fulfil the inclusion criteria.CBCT scans of patients who met the following criteria were included in the study: (i) Egyptian citizenship (ii) 15–65 years old (iii) presence of a fully mature and erupted mandibular second molar. Molars with root canal fillings, posts, crowns, internal or external root resorption, extensively calcified root canals, extensive coronal and root caries and periradicular radiolucency were excluded. The required sample size  with exposure settings of 90 kV, 12.5 mA, 14.966 s, Field of view (FOV) 5.0 × 5.0 cm (one side of the mandible), and voxel size: 75 μm. Images’ acquisition was done by an experienced radiologist. All data from the CBCT examinations were acquired in a digital DICOM format, imported to Planmeca Romexis dental imaging software , and viewed on an 18.5-inch HD LED monitor with a resolution of 1366 Å ~ 768.Examination was performed in March 2022 as detailed in many previous studies , 29, 30.Mandibular second molars were analysed for the following: (i) number of roots, (ii) presence and prevalence of supernumerary roots; radix entomolaris or radix paramolaris, (iii) number of root canals, (iv) prevalence of C-shaped root canal system configuration in which the examined molars should have the following features: (a) fused roots, (b) a longitudinal groove on lingual or buccal surface of the root, and (c) at least one cross-section of the canal belongs to the Fan et al.  criteriap < 0.05 within all tests. Statistical analysis was performed with R statistical analysis software version 4.1.3 for Windows.Weighted coefficient kappa (Kw) was used to measure interobserver reproducibility between observers separately for each time period and to measure intraobserver reproducibility between time periods separately for each observer. Categorical data were presented as frequency and percentage values and were analyzed using chi square test followed by pairwise comparisons utilizing multiple Fisher’s exact tests with Bonferroni correction. Confidence intervals were calculated using the Wilson score interval method . The sigThere was an excellent intraobserver  and interobserver  reproducibility.p = 0.656).The initial analysis showed that 87.1% (95%CI 83.2%:90.3%) of the mandibular second molars were non-C-shaped while 12.9% (95%CI 9.7%:16.8%) were C-shaped, and this was non-significant in relation to gender   (95%CI 79.2%:87.0%) followed by presence of a single root 16.3%) (95%CI 12.8%:20.5%), and only one sample (0.3%) (95%CI 0.1%:1.6%) had three roots, and this was also non-significant in relation to gender .Most samples had three (80%) (95%CI 75.5%:83.9%) followed by two (16%) 95%CI 12.5%:20.2%), then one (3.1%) (95%CI 1.8%:5.5%), and finally four (0.9%) (95%CI 0.3%:2.5%) root canals for both genders (Table .5%:20.2%p < 0.001)  Table . Post hop < 0.001)  , A third root was prevalent in only one sample (0.29%) of the studied subpopulation. This agrees similar studies in Caucasians (1.8%-2.7%) , 38, butRegarding the number and descriptive morphology of root canals, most samples had three (80%) followed by two (16%), then one (3.2%), and finally four (0.8%) canals. This agrees a previous study in an Egyptian subpopulation , as wellWhen the internal anatomy was analysed, the mesial root showed Vertucci type IV (68.8%) configuration to be the most prevalent one in Egyptians followed by Vertucci type II (15.1%). This agrees similar findings in Turks  and IranRoot cross sections were also examined and classified. The most common cross sections were long oval in the mesial root and oval in the distal root followed by the kidney shape in both. This disagrees the findings of Senan et al.  in YeminThe C-shaped molars in this study were found in 12.8% of the examined scans. This percentage is close to that reported in Belgians (10.7%) , SudanesThe C-shaped molars were found more in female than male Egyptians with no significant difference between them. This agrees with reports from Chinese , VenezueRegarding canal configuration of C-shaped molars, C1 was the prevalent coronal configuration, while C3b was the most prevalent one in both the middle and apical thirds. This totally agrees reports in Chinese , VenezueIt is worth mentioning that this classification of Fan et al. 18) was misquoted by some studies as they used the designations C3c and C3d instead of C3a and C3b respectively , 46, 57. was misqThis study adds to the scarce knowledge available about the studied population . Also, tThis study has the limitation of not investigating the ethnicity of the patients because this information was not available to collect and analyze. Also, the symmetric distribution of findings was not possible because only small field of view scans were included for the anatomic analysis. Nonetheless, even studies that showed a high probability of a patient to have C-shaped canals bilaterally still recommend individual evaluation of each mandibular second molar while performing endodontic treatment on both sides , 30, 40.In conclusion, Egyptian permanent mandibular second molars have mainly two separated mesial and distal roots with a very low prevalence of a third one. Various canals configurations were identified, with prevalence for Vertucci Type IV and Type I in the mesial and distal roots, respectively. The occurrence of C-shaped roots and canals must be considered when treating these molars, mainly in females. Also, high resolution, low field of view CBCT is a useful clinical adjunct for successful management of such teeth.