Menstrual period is a critical time in the life of females. For the first few years after menarche, irregular cycle is common due to premature hypothalamic-pituitary ovarian (HPO) axis physiologically. If persistent, it becomes a major problem in student’s life. But few studies conducted on effect of menstrual cycle irregularity on academic performance among university students were descriptive. However assessing the effect of menstrual irregularity on academic performance by using average grade point approach is critically important to magnify its effect.To compare effects of menstrual irregularity on academic performance among undergraduate students of Debre Berhan University, Ethiopia 2020.A comparative cross sectional study was conducted among 404 students in Debre Berhan University, Ethiopia, 2020. A standard tool of menstrual cycle regularity which is prepared by international federation of gynecologist and obstetrics (IFGO) was used to screen students who have menstrual irregularity. Independent sample t- test was done to compare the mean difference of academic performance between the two groups of students.The age of study participants ranges between 18 and 26 years with a mean age of 20.69 ± 1.43 years. The mean age at menarche was 14.9 ± 1.67 ranging from 9 to 18 years. Students who had menstrual irregularity had mean average grade point (AGP) of (2.78 ± 0.57) and students who had regular menstruation had mean AGP of (2.97 ± 0.53). Students who had menstrual irregularity had lower mean average grade point by a mean difference of 0.19 (95%CI: 0.09–0.30).This study found that students who had menstrual irregularity had significantly lower mean AGP as compared with students who had regular menstruation. Regular menstrual cycle  is 21 to 35 days and lasts from 3 to 7 days duration with volume of blood loss 5–80 ml .Menstrual period has a notable effect on the academic performance of female students . It inflThe majority of researches regarding effect of menstrual irregularity have been focused on daily activities and descriptive. However assessing the effect of menstrual irregularity on academic performance by using average grade point approach is critically important. Therefore, the aim of this study was to compare the effect of menstrual irregularity on academic performance by using average grade result of the last semester among Debre Berhan university students.Institutional based comparative cross sectional study design was conducted in Debre Berhan University from February 11 to March 10 /2020. Debre Berhan is located at 130 Kms from Addis Ababa  and at 695 kms from Bahir Dar . There were about 5387 female students during the study period. Undergraduate regular students who were pregnant, who were within one year after delivery and lactating, who had treatment history for menstrual irregularity during the year of study and who were critically ill during data collection period were excluded from the study.The sample size was calculated using a formula for estimation of double population proportion with the assumption of small to medium effect sizes (Cohen’s d = 0.05), 95% confidence interval and a power of 80%. 202 students who have irregular menstrual cycle and 202 students who had regular menstrual cycle were included in the study. The study subjects were selected using simple random sampling (lottery method) technique from the list of the students.A pretested self-administered questioner was used to collect the data. The questionnaire includes socio demographic questions, menestrual cycle pattern related questions, menstrual related symptoms questions, problems faced during menses questions and average grade point of the last semester taken from the students register. The questionnaire was first prepared in English, and translated into Amharic language. A person who was expert in both languages checked the questionnaires’ consistency. Two data collectors  and one supervisor  was participated throughout the data collection process.The investigators want to compare the average grade point of students who have menstrual cycle irregularity with students who have menstrual cycle regularity. In order to assure the comparison similar in academic year only the last one semester average grade point was taken for all students who have regular and irregular menstrual cycle.Whether menstrual cycle is regular or irregular should be determined by using standards of menstrual irregularity definition which was prepared by international federation of gynecology and obstetrics (IFGO) 2018. Therefore, in the present study regular menstrual cycle was defined as if frequency of menses is 24–38 days, duration of bleeding less than or equal to 8 days, cycle to cycle variation over the last one year be less than 10 days and if the individual perception on amount is normal . On the Epi-data version 3.1 was used for data entry and exported to SPSS version 21 software for analysis. Normality test (by using Kolmogorov-Simonov and Shapiro-wilk test), homogeneity of variance (by using Levene’s test) were done. Out layer detection was done by using box and whisker plot. Descriptive statistics such as frequency and percentage were computed for categorical variables. Continuous variables were presented as mean ± standard deviation or median. Independent sample t- test was done to compare the mean difference of academic performance between the two groups of students.The average age of the students was 20.69 ± 1.43 years old with a range of 18–26. Half of respondents 203 (50.20%) came from rural area and 346 (85.60%) of study participants were orthodox Christian followers .The mean menarcheal age of study subjects was 14.90 ± 1.67 ranging from 9 to 18 years. The average duration of the menstrual cycle lasted between 2–12 days with a mean of 4.84 ± 1.81 days.> 8 days), irregular onset was the major problem 123 (30.45%). Light menstrual flow, heavy menstrual flow, prolonged period, frequent period and infrequent period accounts in 116 (28.71%), 80 (19.80%), 24 (5.94%), 23 (5.69%) and 3 (0.74%), respectively , back pain 139 (34.41%), disappointment 94(23.27%) .Related with symptoms, 180 (44.55%) students passed the time without any problem. Others 224(55.45%) students faced different problems. From them 126 (56.25%) had problem of attention in the class .The mean average grade point (AGP) of study participants was 2.88 with (SD ±0.57). Furthermore, 45% of students had an average grade point above the mean. Students who had menstrual irregularity had mean AGP of (2.78 ± 0.57) and students who had regular menstruation had mean AGP of (2.97 ± 0.53) .This study found that students who had menstrual irregularity had significantly lower mean average grade point by a mean difference of 0.19 (95%CI: 0.08–0.30) as compared with students who had regular menstruation .The implications of reproductive health on quality of life and other activities are many. This study examines the association between menstrual cycle and academic performance among undergraduate students of Debre Berhan University. In the present study 56.25% of students had no attention in the class, 31.69% were absent from class, 33.48% decrease class activity, 46.43% had low grade achievement and 5.36% were absent from exam during menses. Moreover, students which had menstrual irregularity had significantly lower mean average grade result as compared with students who had regular menstruation.This is in accordance to the Arabian study, which showed that academic performance was affected by menstruation in several ways, mainly study time (76%), concentration (65.8%), participation in group activities (58.1%), examination performance (51.8%) and class attendance (40.8%) .Another study conducted in Mansoura University revealed that 79.5% of nursing students had sleeping desire during lectures, 78.7% experienced restrictions in practical performance, 77.5% had difficulty in concentration and understanding and 75.1%, decreased participation in discussion. In addition study conducted in Kuwait study 75.5% of the participants perceived menstrual discomfort as having negative effects on their participation . A studyOur study has limitations to consider when interpreting results. First most data on the participant’s questioner were self-reported even Average grade result so social desirability bias may be present.It can be concluded that menstrual irregularity has a major impact on students ‘academic performance. This study found that students who had menstrual irregularity had significantly lower mean average grade point as compared with students who had regular menstruation. But this study give insight about the effect of menstrual irregularity on academic performance, further research should be conducted to study the effect of menstrual irregularity on academic performance on university students.S1 Data(SAV)Click here for additional data file.S1 File(DOCX)Click here for additional data file.


Similar results were obtained for paranasal incidental findings. In a subgroup analysis, 29 of 54 patients showed incidental findings which were previously unknown, and the findings changed therapeutical management in 19 patients (35%). The results of our study highlighted the importance of a meticulous analysis of the entire FOV of CBCT for incidental findings, which showed clinical relevance in more than one in three patients. Due to a high number of clinically relevant incidental findings especially in CBCT for implant planning, an FOV of 100 × 100 mm covering both the mandible and the maxilla was concluded to be recommendable for this indication.Cone beam computed tomography (CBCT) is increasingly used for dental and maxillofacial imaging. The occurrence of incidental findings has been reported, but clinical implications of these findings remain unclear. The study’s aim was to identify the frequency and clinical impact of incidental findings in CBCT. A total of 374 consecutive CBCT examinations of a 3 year period were retrospectively evaluated for the presence, kind, and clinical relevance of incidental findings. In a subgroup of 54 patients, therapeutic consequences of CBCT incidental findings were queried from the referring physicians. A total of 974 incidental findings were detected, involving 78.6% of all CBCT, hence 2.6 incidental findings per CBCT. Of these, 38.6% were classified to require treatment, with an additional 25.2% requiring follow-up. Incidental findings included dental pathologies in 55.3%, pathologies of the paranasal sinuses and airways in 29.2%, osseous pathologies in 14.9% of all CBCT, and findings in the soft tissue or TMJ in few cases. Clinically relevant dental incidental findings were detected significantly more frequently in CBCT for implant planning compared to other indications (60.7% vs. 43.2%,  Until rr larger ,14. Thisr larger  detectedr larger . In thisApproval for this study was obtained from the Institutional Review Board and informed consent was obtained from each patient. First, 374 consecutive CBCT studies that were performed in a period of 33 months in a tertiary hospital were retrospectively reviewed and evaluated for technical parameters and pathological incidental findings. Follow-up imaging was excluded to avoid distortion of the results by therapies that had taken place in the meantime. In case of multiple examinations in one patient, the oldest examination of this patient was analyzed. In a second step, 54 patients out of the 374 patients that were included in the study were reviewed to assess the clinical relevance of the registered incidental findings.2 to 120 × 170 mm2. The voxel sizes ranging from 80 to 260 µm could be selected, depending on the chosen FOV. The indication of the CBCT examination was checked for every patient by a radiologist with expertise. In the vast majority of all cases, an FOV of 100 × 100 mm2  was selected. A voxel size of 250 µm was chosen in 82.4% (308 patients) of all cases for image reconstruction. In summary, 309 examinations were performed with an FOV of 100 × 100 mm2 or larger and a voxel size of 250 µm or more, whereas 65 patients were examined with an FOV < 100 × 100 mm2 and a voxel size of less than 250 µm, respectively . This CBCT device consists of a solid frame construction with a 360° rotatable flat-panel detector. The patient was positioned on a customizable examination chair with fixations for the head and the chin to reduce moving artifacts. After performing two scout images, the FOV was selected out of nine available settings, ranging from 40 × 40 mmectively a,b.The average amperage was 6.5 mA (SD 1.3 mA) with a maximum of 10 mA and a minimum of 3 mA. The average dose length product (DLP) was 116.43 mGy × cm (SD 28.03 mGy × cm) with a maximum of 246 mGy × cm and a minimum of 52 mGy × cm, wherein 50% of the values were between 87 and 140 mGy × cm . The sofEach CBCT examination was assessed with regard to their justifying indication, based on the guideline of the European Commission concerning “Cone Beam CT for Dental and Maxillofacial Radiology” . MultiplIn a second part of the study, a subgroup of 54 patients was selected, who were send to CBCT by the four main referring physicians with long-lasting professional experience. The referring physicians were interviewed by questionnaire on the following statements: 1. did the CBCT examination provide a new diagnosis and/or a new result? (YES or NO) and 2. has there been any change in therapeutic management affected due to a new diagnosis or new result? (YES or NO)?2, implantologic indication, radiation exposure, and dental findings. A two-sided p-value ≤ 0.05 was considered to be statistically significant. Because of the explorative nature of this study, all results from statistical tests had to be interpreted as hypothesis-generating and not confirmatory. An adjustment for multiple testing was not made. Statistical analysis was performed with SAS, version 9.4 .Continuous data were reported as mean, standard deviation, and min-max. Ordinal and categorical data were analyzed as absolute and relative frequencies. Additionally, pie charts were used to visualize the distribution of categorical data. For group comparisons of categorical data, the chi square test or Fisher’s exact test was used as appropriate. Logistic regression analysis was used to determine associations of FOV ≥ 100 × 100 mmIn total, 374 patients including 209 women and 165 men were examined. Patients were 8–90 years old with an average age of 50.9 (±22.3) years.The patients were referred by a total of 59 physicians, including 46 (78%) dentists and 13 (22%) non-dentists, and almost the half of the latter was composed of otolaryngologists. About two thirds of all patients  were referred by dentists without further specialization followed by orthodontists  and otolaryngologists  a. The primary indication for CBCT included implant planning in more than half of the cases , followed by orthodontics  and ENT pathologies  b.In total, 1601 pathological findings were detected among all patients, which was 4.3 pathologies per patient. Out of these, 974 (60.8%) findings were categorized as incidental, involving 78.6% of all patients. These incidental findings included 353 (36.2%) green-, 245 (25.2%) yellow-, and 376 (38.6%) red-rated pathologies. Unbundled to their etiologies, 539 (55.3%) findings originated in dental pathologies, 284 (29.2%) of the findings were located in the paranasal sinuses and airways, and 145 (14.9%) were related to osseous tissue. Four (0.4%) and two (0.2%) pathologies were located in the paramaxillofacial soft tissue and the TMJ, respectively.2, 40.0% of patients showed at least one incidental finding compared to 54.7% of all patients who were examined with an FOV ≥ 100 × 100 mm2 (p = 0.05). There was no significant difference in the detection of incidental findings between examinations with implantologic indication (77.0%) vs. all other indications (84.2%) (p = 0.08). However, 60.7% of the patients with an implantologic indication had red-rated findings whereas less than the half (43.2%) of the other group had red-rated incidental dental findings (p < 0.01). Multiple logistic regression analysis showed significant influence of the implantologic indication with more detected relevant IF. Odds ratio for red IF was 1.88 (95% CI: 1.22 to 2.88). In total, 292 red-, 240 yellow-, and 245 green-rated dental incidental findings were registered. More than 50% of all patients had at least one red-rated dental pathology. Subgroup analysis of red pathologies revealed a significant influence of the FOV: when the FOV was <100 × 100 mm2 compared to an FOV < 100 × 100 mm2 . When focusing on red-rated findings, the difference was even more pronounced: almost three times more incidental findings were registered when using an FOV ≥ 100 × 100 mm2 compared to an FOV < 100 × 100 mm2 (36.9% vs 12.3% p < 0.01) (p < 0.01), favoring the FOV ≥ 100 × 100 mm2 with more detected relevant IF  . The prievant IF . Figure 2 compared to an FOV < 100 × 100 mm2 overall . When focusing on red-rated incidental findings, the total number of these findings was low, and the differences were not significant when comparing FOV ≥ 100 × 100 mm2 vs. FOV < 100 × 100 mm2 . The primary indication for CBCT examination had significant influence on the difference in the frequency detection of osseous incidental findings: among examinations with implantologic indication, 98.4% of CBCT revealed osseous incidental findings compared to only 38.3% on all other indications (p < 0.01). Again, when focusing on red-rated findings, the difference between both indication groups was statistically not significant . Multiple logistic regression analysis showed no significant influence of both, indication implantology and FOV, on relevant IF. Odds ratio was 1.04 (95% CI: 0.49 to 2.23), p = 0.91) for indication implantology and 1.93 (95% CI: 0.55 to 6.80) for FOV, respectively. In total, 33 red-, 54 yellow-, and 342 green-rated osseous incidental findings were detected. About 8% of all patients had at least one red-rated osseous pathology. Significantly more osseous incidental findings were registered when applying an FOV ≥ 100 × 100 mmp = 1.00).No green-rated and only three yellow-rated soft tissue incidental findings were registered. Merely one red-rated finding of an ill-defined enlarged submandibular lymph node was detected. There was no significant difference in the frequency of incidental soft tissue findings regarding implantologic indications or FOV (p = 0.03). All five relevant yellow IF were found in patients without an implantologic indication.Incidental pathologic findings of the TMJ were registered in only five patients. Clinical relevance was classified as “yellow” in all of these cases. There was significant influence of indication regarding implantologic indications , 98 incidental diagnoses were newly detected by the CBCT examination, including 25 green-, 19 yellow-, and 54 red-rated pathologies. Within the red-rated findings, dental pathologies were most frequent with 75.9% (n = 41) followed by pathologies of the paranasal sinuses with 18.5% (n = 10) and osseous pathologies with 5.6% (n = 3). In 19 patients (35.2%), the therapy management was altered due to new diagnoses. In these particular patients, a total of 63 pathological findings were detected, including 37 (58.7%) red-rated pathologies. Within these red-rated findings, there were 25 patients with periradicular disease (67.6%) and 5 (13.5%) with pathologies of the paranasal sinuses. Seven patients had other pathologies (18.9%) .In accordance with guidelines ,19 and o2 or larger. This size of FOV reliably covers the entire maxillary and mandibular dental arch and allows the evaluation of the adjacent structures of the midface that are potentially relevant for the planning of dental therapies. Alareddy et al. published the actual largest number of cases focusing on incidental findings in dental imaging, with an FOV of 130 × 130 mm [2 up to 220 × 220 mm2. Our mainly used FOV with 100 × 100 mm2 was rather small compared to the studies mentioned above. In some other studies, a smaller FOV was chosen [More than 80% of the examinations that were included in our study were performed with an FOV of 100 × 100 mm× 130 mm . Edwards× 130 mm . Other a× 130 mm ,13,15. Ps chosen ,26,27. Ts chosen . A pathos chosen ,12,28,29We detected 2.6 incidental findings per patient with 78.6% of all patients showing incidental findings. In the study of Price et al., 272 CBCT scans revealed 881 incidental findings, equivalent to 3.2 per scan . CaglayaPublished reports differ significantly concerning the type and localization of incidental findings. Price et al.  as well Differences between published studies were also found concerning the frequency of indication for a CBCT examination. In contrast to our and most other studies, Caglayan and Tozoglu included only 15 out of 207 patients for implant planning . Despite differences in study concepts, composition of patient groups, or indications, our results are broadly in line with other published data and demonstrated a high frequency of incidental pathological findings in CBCT of the maxillofacial region, whether they were in the region of interest or not ,21,22,262, covering both the mandible and the maxilla in the context of an implant planning situation. The high incidence of 80% of dental incidental findings in all patients outlines the clinical importance of a meticulous image analysis. More than the half of all findings were classified as clinically relevant. “Red” clinically relevant dental as well as airway incidental findings occurred in 61% of CBCT for implant planning, and thus almost 50% more frequently in patients who were admitted to CBCT for implant planning compared to CBCT for other indications. This might be explained by a generally lower sanitary dental status and a higher incidence of paranasal sinusitis in patients who need dental implants ,32. Cons2, especially when regarding dental incidental findings as well as implantologic indications for CBCT. It could be assumed that at least some of these incidental findings may have been missed if the FOV was limited too close to the site of primary clinical interest [In nearly every second patient of our subgroup with extended clinical analysis, a new diagnosis was found that was not known before CBCT examination. In two thirds of patients with these new detected diagnoses, the therapeutic management had to be adjusted. This is different to the results of Lopes et al., where most of the detected IF were classified not to undergo further treatment or referral to another professional . Our subinterest . PossiblRadiologists must deal with a holistic diagnostic work-up covering a clinically reasonable area that is not obligatorily limited to the scope of the referring specialist. This work-up includes especially the detection and description of incidental findings. Radiologists should deal and familiarize with the specific analysis of CBCT to minimize the possible consequences for the patients of missing incidental findings. This emphasizes again the importance of close collaborations between medical and dental specialties as Khalifa et al. recently pointed out .CBCT of the maxillofacial region revealed a high percentage of clinically relevant additional findings. This study presents data underlining the clinical relevance of these findings. Our results confirmed the influence and dependency of the findings on the FOV and the primary indication, especially for implant planning. The “incidental” findings induced a change of therapy in more than one in three patients. Due to a high number of clinically relevant incidental findings in CBCT for implant planning, an FOV of 100 x 100 mm was concluded to be recommendable for this indication. A meticulous analysis of the entire FOV is essential.


To investigate the change of posterior capsular outcomes of pediatric cataract surgery with primary in-the-bag intraocular lens (IOL) implantation.register.clinicaltrials.gov (NCT04803097).We conducted a case series of pediatric cataract children who underwent cataract extraction with primary in-the-bag IOL implantation, posterior capsulorhexis or vitrectorhexis, and limited anterior vitrectomy at the Eye Hospital of Wenzhou Medical University between 2016 and 2019. Digital retro-illumination photographs of pediatric eyes were obtained at baseline and 6 months, 12 months, and the last visit postoperatively. Capsular outcomes of the posterior capsular opening area (PCOA) and lens reprolifration area at those time points were compared. Correlations between the PCOA and influential factors, such as age at surgery, axial growth, and follow-up duration, were analyzed. The study was registered at 2/month during the first six months postoperatively and 0.05–0.08 mm2/month over the next 1–2 years. Six months postoperatively, the PCOA enlargement statistically and positively correlated with the follow-up duration and axial growth. The area of lens reprolifration was 0.46 ± 1.00 mm2 at six months postoperatively and then remained stable.Data of 23 patients (27 eyes) were used in the final analysis. During follow-up, the PCOA enlarged at a rate of 0.29–0.32 mmThe PCOA enlarged rapidly within the first six months after the pediatric cataract surgery with primary IOL implantation. Six months postoperatively, the enlargement of PCOA was positively correlated with follow-up duration and axial growth. Posterior capsulorhexis or capsulectomy should be performed with a diameter of 3.0 to 4.0 mm for good visual axis transparency and the protection of in-the-bag IOL. Pediatric cataract surgery is challenging because of the high complications including visual axis opacification (VAO), posterior capsulorhexis opening reclosure, anterior capsule contraction, intraocular lens (IOL) eccentricity, IOL dislocation, zonular dehiscence, secondary glaucoma, and so on –4. Some Many ophthalmologists have realized that capsule management during pediatric cataract surgery is one of the critical components determining the final postoperative prognosis for vision . Due to register.clinicaltrials.gov: NCT04803097.The study was registered at Children who underwent cataract surgery and primary IOL implantation at the Eye Hospital of Wenzhou Medical University  between 2016 and 2019 were included in the study. The research protocol was approved by the Institutional Review Board and Ethics Committee of Wenzhou Medical University and was conducted according to the tenets of the Declaration of Helsinki. Informed consent was obtained from the parents of all participating children. We excluded patients with ocular trauma, corneal disorders, glaucoma, preoperative lens luxation or subluxation, membranous cataract, persistent hyperplastic primary vitreous, surgical or postoperative complications such as glaucoma or suspect-glaucoma and synechia, pupils that could not be sufficiently dilated, and those who could not complete follow-ups or did not have clear digital photographs. The follow-up period was at least one year.2O, cutting rate 3000 cpm, flow rate 10 cc/min, vacuum 350 mmHg. The diameter of the anterior capsular opening was about 5.0–5.5 mm, and the posterior capsular opening was about 3.0–4.5 mm. The anterior and posterior vitrectorhexis or capsulorhexis diameters were controlled using a spatula with laser markers  (Surgery was performed by the same experienced surgeon (Z.Y.E.). All surgeries were performed under general anesthesia. A 2.2-mm scleral tunnel incision was created at a 12’o clock position and followed by two corneal incisions (1.0mm). For patients older than three years, we performed lens aspiration after anterior continuous curvilinear capsulorhexis, followed by posterior continuous curvilinear capsulorhexis and limited anterior vitrectomy with a 23-gauge microincision vitrectomy system . While in patients younger than three years old, anterior and posterior vitrectorhexis was performed instead of manual capsulorhexis. The parameters of the Accurus vitrectomy system were set as follows: bottle height 50–60 mmHm scale) . Then, am scale) . The IOL2O). All captured images were required to focus on the posterior capsular opening area (PCOA) and visual axis transparent area (VATA)  .Postoperatively, topical eye drops containing 0.3% tobramycin and 0.1% dexamethasone were used four times daily for four weeks, and compound tropicamide eyedrops were used once a day for one month. All patients were examined at 1 week, 2 weeks, 1 month, 3 months, and 6 months postoperatively. After that, patients younger than three years of age were followed up every three months postoperatively for at least one year, and patients three years or older were followed up every six months postoperatively. Visual acuity examinations, refraction, IOP measurements , and fundus examinations were performed. Axial length measurements  and slit-lamp-adapted anterior segment photography  were performed at 6, 12, and 18 months postoperatively and then every six months after that. All pediatric patients underwent postoperative pupil dilation with compound tropicamide eye drops three to five times (once every 10 min) until the pupils were fully dilated. Then, slit-lamp-adapted anterior segment digital photographs of each operated eye, including one digital coaxial retro-illumination photograph, were obtained. The patients were sedated through intranasal administration of dexmedetomidine for children who could not cooperate during examinations .Both intraoperative and postoperative pictures were standardized and documented on an analysis computer using ImageJ software , as follows : After tp-value of < 0.05 was considered statistically significant.The SPSS software package  was used for statistical analyses. Data were checked for normal distribution using the Kolmogorov–Smirnov test. A single-sample repeated analysis of variance with Bonferroni correction was used to analyze the parameters observed at all visits. Depending on the data distribution, a Pearson or Spearman correlation analysis was performed to assess the relationship between the PCOA or lens reproliferation and influential factors such as age at surgery. The sample size, which was determined to be 23 subjects , was calculated for the same primary outcome measure (PCOD) using the PASS software . A Fifty patients (62 eyes) were included in the study. Of these, we excluded 16 patients (20 eyes) due to incomplete follow-up or non-cooperation with the examination; 9 patients (13 eyes) because of poor image quality with insufficient pupil dilation; and 2 patients (2 eyes) because of VAO . Finally, 23 patients (27 eyes) were included in the final analysis of parameters at baseline, 6 months postoperatively, and the last postoperative visit (20.74 ± 7.89 months). The average age of patients at surgery was 3.50 ± 1.80 years , including 7 patients (8 eyes) younger than two years of age. There were 12 male and 11 female patients. No severe complications occurred during surgery and the follow-up period. Similarly, there was no noticeable shrinkage or capsular contraction in any of the 27 eyes.2/month in the first six months, and 0.08 mm2/month from 6 months to the last follow-up (20.74 ± 7.89 months) postoperatively; the corresponding growth rates of PCOD were 0.05 mm/month and 0.01 mm/month, respectively.2, 13.38 ± 3.49 mm2, 13.70 ± 3.52 mm2, and 14.67 ± 3.77 mm2, respectively; the corresponding PCODs were 3.79 ± 0.54 mm, 4.10 ± 0.53 mm, 4.15 ± 0.53 mm, and 4.29 ± 0.56 mm, respectively. After surgery, the growth rates of PCOA were 0.32 mm2/month in the first six months, 0.05 mm2/month from 6 to 12 months, and 0.07 mm2/month from 12 months to the last follow-up (25.64 ± 6.62 months); the corresponding growth rates of PCOD were 0.05 mm/month, 0.01 mm/month, and 0.01 mm/month, respectively.Twelve of 23 patients (12 eyes) were available to analyze parameters observed at baseline and 6 months, 12 months, and the last visit (25.64 ± 6.62 months) postoperatively. The corresponding PCOAs were 11.46 ± 3.27 mm2 in patients < 2 years of age and 1.70 ± 1.23 mm2 in patients > 2 years of age . In the period from six months after surgery to the last follow-up, the PCOA growths were 1.08 ± 0.39 mm2 in patients < 2 years of age (follow-up time 18.00 ± 8.48 months) and 1.16 ± 0.63 mm2 in patients > 2 years of age .In the study, there were a total of 8 eyes from 7 patients younger than two years of age , and 19 eyes from 16 patients older than two years of age . In the first six months postoperatively, the PCOA growths were 1.80 ± 0.72 mmN = 27 eyes) in the first six months after surgery did not correlate with axial length growth or age at surgery. However, the difference in PCOA from six months to the last visit postoperatively demonstrated a statistically significant positive correlation with the growth of axial length and the corresponding follow-up duration but not with age at surgery  and at 0.07 mm2/month during the next six months postoperatively (12.46 ± 2.95 mm2 at 12 months). This trend is similar to our findings, although their baseline was marginally different. Therefore, with or without the IOL implantation, the PCOA expands rapidly in the first six months after surgery due to inflammation or LEC reproliferation and subsequent fibrosis, and then this expansion gradually decreases. As our follow-up period was relatively short, we still need to investigate when the PCOA reaches a steady state.This is the first study to investigate changes in capsular outcomes after pediatric cataract surgery with primary IOL implantation to the best of our knowledge. We took digital retro-illumination photographs and then analyzed the PCOA through Image J software similar to the previous studies . HoweverThe size of the anterior capsulorhexis may affect the degree of change of capsular outcomes in pediatric cataracts. Lin et al.  reportedData from 12 eyes  revealed that the rate of PCOA enlargement in 2 to 25.64 ± 6.62 months of follow-up was similar to that in 6 to 12 months of follow-up. Age was often a factor because of the increased risk of capsular-related complications following cataract surgery with intraocular lens implantation in children younger than two years . We enroIOL material and design may influence capsular outcomes . During For better intuitiveness, areas were converted to corresponding diameters for better guidance during surgery. The PCOD enlarged at a rate of 0.05 mm/month during the first six months after surgery; then, it enlarged at a slower rate of 0.01 mm/month. Accordingly, the PCOD is estimated to enlarge by approximately 0.5 mm in the first two years after surgery and may enlarge continuously thereafter, although a longer follow-up is required to confirm it. Therefore, it is reasonable to expect that the PCOD may enlarge 0.5- to 1.0-mm postoperatively. Generally, a 3.0- to 5.0-mm diameter of the posterior capsulorhexis is acceptable during pediatric cataract surgery , 31. ConAt the last postoperative visit, lens reproliferation was acceptable in all eyes. In pediatric cataracts, LEC proliferation decreases with age . VAO indThis research studied the changes in capsular outcomes 1 to 2 years after pediatric cataract surgery with primary IOL implantation and demonstrated the PCOA expansion after the surgery. One limitation of this research was its relatively short follow-up period. We aim to follow up with these patients for a more extended period. Another limitation was the lack of ACO measurements. Indicators such as cornea diameters need to be further evaluated to understand the relationship between ocular development and changes in capsular outcomes.In conclusion, the PCOA enlarged after surgery, and the enlargement was positively correlated with the follow-up duration and axial length growth. The anterior capsulorhexis diameter of 5.0–5.5 mm used in our study was safe and suitable for pediatric cataract surgery with IOL implantation, with a low incidence of severe contraction of the capsular opening and VAO. The posterior capsulorhexis or vitrectorhexis size should be considered to ensure good long-term prognoses. We recommend a posterior capsulorhexis or vitrectorhexis diameter of 3.0–4.0 mm for good visual axis transparency and protection of in-the-bag IOL.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The research protocol was approved by the Institutional Review Board and Ethics Committee of Wenzhou Medical University, and was conducted according to the tenets of the Declaration of Helsinki. Informed consent was obtained from the parents of all participating children. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.YF drafted the manuscript and collected patient information. DW and XD analyzed and interpreted the patient data. PC and YZ collected data. MH and ZL edited the patient photos. Y-eZ critically revised the manuscript for intellectual content and supervised the project. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The microbial loads seemed somewhat acceptable as overall acceptability favoured sample WDFb . The acceptability of cookies baked at 160 °C over those baked at 180 °C suggests the need for further studies to determine the energy requirements, and long-term environmental implications such (baking) temperatures would pose.Studying the effects of temperature on cookies are necessary especially if the impact on quality attributes are to be deduced. More so, blending wheat flour, date flour, and pineapple juice could improve the nutrient quality required in modern-day cookies. This current study investigated the quality attributes of date and wheat flour pineapple juice blended cookies as affected by different baking temperatures. With pineapple juice serving as water substitute, the formulated date, and wheat flour blends adhered to the following ratios: 100:0, 90:10, 80:20, and 70:30. Baking cookies involved two different temperatures (160 °C and 180 °C) with constant time (30 min). Quality attributes determined proximate composition, micronutrients, physical and functional properties, and microbial and sensory qualities. Cookies proximate results showed moisture (6.89–7.40%), protein (8.73–10.22%), fat (14.37–15.99%), fiber (1.02–1.11%), ash (0.77–1.20%) and carbohydrate (64.85–67.71%). Various ranges appeared, from energy values , minerals , vitamins , physical (weight = 7.4–7.75 g; diameter = 3.50–4.01 cm; thickness = 0.99–1.20 cm; volume = 3.11–3.77 cm The pulp with pericarp was then oven dried at 75 °C for 6–8 h and subsequently milled using a hand milling machine and sieved through a 0.35 mm mesh sieve to obtain fine homogenized particles . The pinA two-component augmented mixture design was used to assemble the blends of wheat and date flours by sample ratio, which were as follows: WFa (100:0) representing 100% wheat flour, 0% date flour; WDFb (90:10) representing 90% wheat flour, 10% date flour; WDFcm (80:20) representing 80% wheat flour, 20% date flour; and WDFd (70:30) representing 70% wheat flour, 30% date flour. This enabled the study design to produce four mixtures, with proportions for each ingredient applicable to each treatment combination. Additionally, the recipe for cookies production involved the following ingredients with their respective quantities: flour = 500 g, sugar = 100 g, baking fat = 180 g, salt = 2 g, baking powder = 2.5 g, baking soda = 2 g, water, = 80 mL and pineapple juice = 80 mL. The ingredients were weighed and mixed thoroughly into a dough. The dough was rolled on a board (with flour spread on it to avoid sticking) using a rolling pin. The rolled batter was cut into shapes and arranged on a greased baking tray and were placed in an electric oven facility . According to Proximate compositions, which included moisture content, crude fibre, crude fat, crude ash, crude protein, and carbohydrate, together with energy values of samples were determined using the official methods of analysis .Functional properties involved bulk density, and water and oil absorption capacities. The bulk density of the flour blends was determined according to the method of The bulk density (BD) was calculated as:3); W1 = Weight of empty cylinder (g); W2 = Volume of cylinder + sample (g); V = Volume of cylinder occupied by the sample (cm3).g for 30 min. The volume of free water or oil (supernatant) was read directly from the graduated centrifuge tube. The absorption capacity was expressed as a gram of oil or water absorbed (or retained) per gram of sample.The water and oil absorption capacities of the formulated samples were determined using the method described by 3), and density (g/cm3) values according to the Approved Methods of the American Association of Cereal Chemists , thickness (cm), and average weight (g) of the cookies, which helped to calculate the speed ratio (SR), volume . The averages of the colonies from duplicates were determined.Microbial load determinations involved total viable count (TVC) and mould count (MC). With respect to TVC, the method of −1) was pipetted into duplicate Petri dishes. Also, 15 mL of SDA (Sabaroud and Dextrose Agar) was pipetted aseptically into the Petri dishes. These Petri dishes were swirled in order to mix the content thoroughly, allowed to solidify and turned upside down thereafter. Petri dishes were incubated for 48 h at room temperature. The mould counts were expressed as cfu/g (colony forming unit per gram) of the samples.With respect to mould count, method described by The cookies samples were evaluated for color, flavour, taste after taste, texture, mouthfeel, crispness and overall acceptability on a nine-point Hedonic scale where nine (like extremely) was the highest and one (dislike extremely) was the lowest score. The evaluation was done by 20 semi-trained panelists selected from the students of the Department of Food Science and Technology, University of Nigeria, Nsukka. The panelists during their studies had undertaken sensory training, and therefore were familiar regards various evaluation criteria specific to the cookies. Participation was voluntary, verbal consent was taken, and no information regards the panelists were taken. The samples were coded and presented without further treatment in coded plastic plates to the panelists randomly during the day. The order of presentation of the samples was randomized. Clean water was presented to the panelist to rinse their mouth in between samples, to ensure the previous sample tested did not influence the new, adhering to report of p < 0.05. Statistical Product for Service Solution (SPSS) version 25.0 was used to run the data.Results from two determinations independently measured from different samples were submitted to analysis of variance (ANOVA). Duncan’s new multiple range tests (DNMRT) were used to compare the treatment means. Statistical significance was accepted at d (6.89%) and WDFc (7.40%) having the least and highest moisture content, respectively. Significant (p < 0.05) differences were observed between all the samples. Increasing the baking temperature from 160–180 °C steadily decrease in moisture content, like samples WDFb (7.26–6.61%), WDFc (7.58–7.23%) and others. Besides samples with the same formulation baked at two temperatures produced different moisture content effects, there was significant interaction (p < 0.05) between the formulation and baking temperature, seemingly to agree with data of In a (10.22%) with 100% wheat flour as peak, and sample WDFd (8.73%) with 70% wheat and 30% date flour as least protein content. An increased substitution of wheat with date flour in the formulation led decreased protein content in the cookies. According to b (9.57%), WDFc (9.42%) and others. This steady increase could be that at high temperatures, proteins are denatured and anti-nutrients would be bound to proteins being liberated from the sample leading to available proteins at high temperatures (In eratures .p < 0.05) in protein occurred across all the samples, like with sample WFa with 100% wheat flour. Also, a significant (p < 0.05) interaction term between the formulation and the baking temperature seemed apparent. More so, the quality and nutritional content of food are a simultaneous function of both formulation and processing methods (a (15.99%) with 100% wheat flour having the highest and sample WDFd (14.37%) with 70% wheat and 30% date flour having the lowest fat content. Probably, fat content reduction across the formulations occurred because of date flour. Baking temperatures increased with fat content for samples with resembling formulation baked at different temperatures as seen in samples WDFb (15.34– 15.45%), WDFc (14.43–14.55%) and in other samples. Moreover, the lowering of moisture resulted to fat concentration in the formulated cookies. Notably, fats can withstand high-temperature processing with little changes (p < 0.05) cross-interaction seemed apparent between the formulation and baking temperature.Significant differences ( methods . Table 1 changes . Additioa (1.02%) as a minimum, and WDFd (1.11%) as the maximum. The inclusion of date flour during formulation steadily increased with fibre content, similarly reported by p > 0.05) difference between sample WDFb (1.06%) and WDFc (1.07%). Besides, the ash content ranged from 0.77–1.20% with sample WFa (0.77%) and WDFd (1.20%) having the lowest and highest, respectively (b (0.60–1.22%), WDFc (0.52–1.31%) and in other samples. Date palm fruits according to p < 0.05) interaction was also observed, although there was no significant (p > 0.05) difference between sample WDFb (0.91%) and WDFc (0.92%).In ectively . The adda (64.85%) as minimum and WDFd (67.71%) as maximum. Significant differences (p < 0.05) were observed between all the samples. The substitution of date flour in the flour blends increased with the carbohydrate content of the cookies. The results obtained in carbohydrate content were similar to the results of a  as the maximum, and sample WDFc  as a minimum. Between the formulation and temperature, there was no significant (p > 0.05) difference between sample WFa  and WDFb. . The energy value reduction could be due to higher protein and fat contents in wheat flour (control) above those used in formulations supplemented with date flour. Also, the concentration of fats, carbohydrates, and proteins could be a result of moisture loss during formulation at high temperatures (160–180 °C) with an increase in energy content.In a (33.18 mg/100 g) with 100% wheat flour and sample WDFd (62.45 mg/100 g) with 30% substitution of date flour respectively. An increased inclusion of date flour in the formulation resulted in an increase in the Ca content of the cookies with significant (p < 0.05) differences observed between all the samples as seen in samples WDFb (53.32 mg/100 g), WDFc (58.62 mg/100 g) and in other samples. Compared to wheat, the Ca content increased with inclusion of date fruit flour. This happened probably due to high amount of calcium present in date fruit  and sample WDFd (5.75 mg/100 g), respectively. The iron content increased in the formulation with the increased inclusion of date flour as seen in samples WDFb (2.26 mg/100 g), WDFc (5.38 mg/100 g) and in other samples. This could be due to the high iron content of date flour compared to wheat flour. Significant (p < 0.05) differences were observed in the iron content with sample WDFd (5.75 mg/100 g) with 30% substitution significantly higher than the other samples. The two baking temperatures employed in the production did not significantly affect (p > 0.05) the iron content of the cookies. The results obtained for the iron content were higher than the values (1.40–2.76 mg/100 g) reported by In a (100.07 mg/100 g) and sample WDFd (358.63 mg/100 g), respectively. An increased inclusion of date flour in the formulation resulted in an increase in the potassium content of the cookies with significant (p < 0.05) differences observed between all the samples as seen in samples WDFb (312.34 mg/100 g), WDFc (321.74 mg/100 g) and in other samples. An increase in the potassium content with increased inclusion of date flour could be due to the high amount of potassium reported to be present in date flour compared to wheat. A change in baking temperature did not significantly affect the potassium content of the cookies.In d  with 30% substitution of date flour was higher than the other samples. This could be due to the high amount of vitamins A and C concentrated in date flour. The vitamins A and C contents were higher for samples with the same formulation and baked at 160 °C compared to samples baked at 180 °C. Vitamins A and C are sensitive to temperature changes and degrade at high temperatures. This could explain the reason why an increase in baking temperature reduced the vitamin A and C contents of the cookies as seen in samples WDFb (4.07–4.06 mg/100 g), WDFc (4.47–4.35 mg/100 g) and in other samples. Also, a significant interaction between the formulation and baking temperature suggests these vitamins in cookies simultaneously function with the formulation/treatment given to the sample  and WFa (7.75 g), respectively (p > 0.05) differences were observed between samples WDFc (7.49 g) and WDFd (7.49 g) with 20% and 30% substitution of wheat flour with date flour. Sample WFa (7.75 g) with 100% wheat flour was significantly (p < 0.05) higher than all the samples in terms of average mass. The high average mass could be due to the fact that nutrients and matter are more concentrated in wheat flour compared to date flour. Results for average mass were lower than the values of The average mass of the cookies ranged from 7.49–7.75 g for samples WDFectively . No signa (3.50 cm) with 100% wheat flour and sample WDFd (4.01 cm) substituted with 30% date flour, respectively (p < 0.05) differences as seen in samples WDFb (3.80 cm), WDFc (3.98 cm) and in other samples. The diameter increased with inclusion of date flour, probably because of reduced protein gluten. Moreover, substituting wheat decreased dough viscosity and resulted in a high flow rate leading to increased diameter of the cookies  and WFa (1.20 cm), respectively (b (1.11 cm), WDFc (0.99 cm) and in other samples. For samples with the same formulation and baked at different temperatures, there was no significant (p > 0.05) difference in thickness. Such a decrease in the thickness could be due to the dilution of wheat gluten by date fruit (The thickness of the cookies ranged from 0.99–1.20 cm for samples WDFectively . Increaste fruit . The higte fruit . Resultste fruit .3 for sample WDFd (3.11 cm3) with 30% date flour and sample WFa (3.77 cm3) with 100% wheat flour, respectively (p < 0.05) differences observed among the samples except for samples WDFc (3.11 cm3) and WDFd (3.11 cm3). Samples with the same formulation despite being baked at different temperatures show no significant (p > 0.05) difference by volume. Reduction in volume with increased substitution of wheat flour with date flour could associate with the high fibre content of date fruit flour. Fiber can help reduce dough spread during baking, which strengthens its resistance to deformation (The volume of the cookies ranged from 3.11–3.77 cmectively . An incrormation . However3 for sample WFa (2.06 g/cm3) with 100% wheat flour and sample WDFd (2.41 g/cm3) with 30% date flour, respectively (b (2.14–2.15 g/m3), WDFc (2.40–2.41 g/cm3) and in other samples. Sample WDFd (2.41 g/cm3) with 30% substitution was significantly (p < 0.05) higher than the other samples. No significant (p > 0.05) difference happened between samples with resembling formulation and baked at the two baking temperatures (160 and 180 °C). Probably, the increase in density of the cookies could arise from the addition of fibrous matter coming from date fruit flour.The density of the cookies ranged from 2.06–2.41 g/cmectively . Resultsa (2.92) with 100% wheat flour and sample WDFd (4.05) with 30% date flour, respectively (d (4.05) significantly (p < 0.05) higher than the other samples. The increase in spread ratio with the increased addition of date flour could be due to the restriction of dough viscosity. Cookie spread represents the ratio of diameter to thickness. Cookies’ spread ratio appears to be controlled by dough viscosity; dough with low viscosity causes cookies to spread more rapidly compared those with high viscosity (The spread ratio of the cookies ranged from 2.92–4.05 for sample WFectively . The resiscosity . Cookiesiscosity . Cookiesa (1.18 g/g) with 100% wheat flour and sample WDFd (1.14 g/g) with 30% date fruit flour substitution, respectively. Increased addition of date flour in the formulation reduced the WAC with sample WFa significantly (p < 0.05) higher than the other samples. High WAC in sample WFa (1.18 g/g) could be due to protein and starch molecules in wheat flour creating hydrogen bonds and hydrophilic interactions with the added water molecules in the flour. Water molecules hydrate the gluten-forming proteins gliadin and glutenin, as well as damaged starch and other ingredients (b (1.15 g/g), WDFc (1.14 g/g), and WDFd (1.14 g/g) could therefore be due to a dilution effect of wheat starch and protein by date flour. Values obtained for water absorption capacity were in the range of values (1.00 to 1.60) reported by In redients . Lower va (1.31 g/g) with 100% wheat flour and sample WDFd (1.33 g/g) with 30% date fruit flour substitution, respectively. The oil absorption capacity as observed increased with an increased substitution of wheat flour with date flour. Fat content of the samples could also be attributed to the margarine added. Sample WFa (1.31 g/g) was significantly (p < 0.05) lower than the other samples, with no significant (p > 0.05) difference seen between sample WDFc (1.33 g/g) and WDFd (1.33 g/g). Oil absorption in starch relies predominantly on the physical entrapment of oil within the starch structures. This is because starch does not have nonpolar sites, compared to those found in proteins (In proteins . The incd (0.74 g/mL) with 30% date fruit flour substitution and sample WFa (0.76 g/mL) with 100% wheat flour and respectively (a (0.76 g/mL) was significantly (p < 0.05) higher than all the other samples but no significant (p > 0.05) difference was observed for the different substitution levels. Bulk density is the mass per unit volume of food. It is also indicative of how porous the food product is, and how it can be packed together. Values obtained for bulk density were within the range of values earlier reported by The bulk density of the flour samples ranged from 0.74–0.76 g/mL for sample WDFectively . The res4 to 7.7 × 104 CFU/g) reported by etc.In b (6.23) and WDFd (7.45), respectively. No significant (p > 0.05) difference was observed across samples WDFd (7.45), WDFc (7.10), and WDFa (6.95), despite the highly rated colour for WDFd, probably due to the desirable brown date flour colour in the formulation. Generally, samples baked at 160 °C appeared more appealing compared to samples baked at 180 °C for the sample formulation. Baking temperatures as well as formulation significantly (p < 0.05) affected the colour of the blend samples. Besides Lagenaria siceraria) seed cake fortified biscuit occurred with increased baking temperature(s). Lower values could be due to the intense brown colour of the cookies that resulted from a caramelization reaction. The color results of cookies herein seems to agree data reported by In b (6.83) and WDFd (7.08), respectively. There were no significant (p > 0.05) differences in flavour between samples baked at 160 °C and samples baked at 180 °C, although samples baked at 180 °C were having lower values. This could be attributed to the fact that at higher baking temperatures, the flavouring volatiles in the samples was more prone to lose. Also, the interaction between the two treatments (formulation and temperature) did not significantly (p > 0.05) affect the flavour as perceived by the panelist. Results obtained in flavour were higher than the values reported by b (6.85) and WDFc (7.30), respectively. Significant (p > 0.05) differences were not observed in terms of taste for samples produced with different formulations, although an increase in baking temperature reduced scores for the taste. This agreed with the results reported by p > 0.05) interaction effect was observed. Further, the taste results of the cookies seem to agree with the data reported by In b (6.63) and WDFd (6.85), respectively. There were resembling (p > 0.05) among the samples. Temperature variation did not significantly affect the aftertaste despite the lower values at samples baked at 180 °C. High ratings for aftertaste may associate with processing temperatures unable to burn the samples. Moreover, the interaction between the processing temperature and samples obtained a significant effect (p < 0.05) specific to the aftertaste, which tends to reflect the opinion of a (6.95) and WDFc (7.33), respectively. Thus, the increased substitution of wheat flour with date fruit flour occurred with texture, even though the mean scores across the samples resembled (p > 0.05). More so, the interaction between the processing temperature and the formulation also resembled (p > 0.05) by texture as rated by the panelists.The sensory scores in the aftertaste of the cookies ranged from 6.63–6.85 for sample WDFa (6.93) and WDFb (7.35), respectively. Significant (p > 0.05) differences were not observed between samples. The cookies baked at 160 °C were generally preferred by the panelist compared to the cookies baked at 180 °C. The mouthfeel is a sensation acquired when food is placed in the mouth and it is very important in sensory ratings for overall acceptability. High ratings by the panelist could be indicating a pleasant sensation of the cookies in the mouth. The interaction between the mixture formulation and the baking temperature was insignificant (p > 0.05). p < 0.05) between samples WFa (6.85) and WDFb (7.63). Both crispness/crunchiness are textural attributes often associated with freshness/firmness of natural manufactured foods (In ed foods . The crued foods . An incla (7.00) as a minimum, and WDFb (7.30) as a maximum. There was no significant (p > 0.05) difference between the treatment temperatures on the overall acceptability even though panelists gave higher values on cookies baked at 160 °C compared to samples baked at 180 °C. An increase in the baking temperature led to a decrease in the overall acceptability of the samples, which seemed to agree with the results observed by Lagenaria siceraria) seed cake fortified biscuit. Formulation and processing temperature appeared not to affect overall acceptability (p > 0.05). Values for the overall acceptability were higher than the values reported by b (7.30) was more preferred followed by sample WDFc (7.28), then sample WDFd (7.15), and WDFa (7.00), respectively.In Promising quality cookies can be produced from blends of wheat and date flour with pineapple juice. Date flour probably accounted for increased the ash, fibre, mineral, and carbohydrate content of the cookies. Cookies baked with 70% wheat and 30% date flour with pineapple juice had the highest nutrient retention. Cookies having a higher spread ratio could be more desirable, especially those baked with 90% wheat, and 10% date flour with pineapple juice. Also, cookies baked at 160 °C appeared more acceptable compared to the cookies baked at 180 °C. Studying the influence of different baking temperatures has a direct link with moisture/water, and therefore energy. Considering that the food, water, and energy nexus demands a broad scope, which should not be seen only to directly relate to climatic context, but should also be seen to indirectly relate to climatic context, the acceptability of cookies baked at 160 over those baked at 180 °C points to why the results of current work serve as a foundation further studies to specifically determine the energy requirements, and long-term environmental implications that this baking (temperature) position would pose.10.7717/peerj.14876/supp-1Supplemental Information 1Click here for additional data file.


Acute measles encephalitis is a pathology of the central nervous system. It is most frequent in children but can also be described in adults. Given the rarity of this pathology, we present the case of this patient.To assess perfectionism and depression and to study the relationship between these two parameters in a population of medical students.We conducted a descriptive and analytical cross-sectional study among students of the Faculty of Medicine of Sfax during the months of June, July, and August 2020. The data were collected through a self-questionnaire disseminated on the social network “Facebook”.This questionnaire included identification of socio-demographic characteristics as well as the personal history of students. Perfectionism was assessed by the Rheaume scale and depression by the Beck scale.A total of 206 students participated in the survey. The mean age was 21.49 ± 1.37 years. The majority of students were female (57.2%) with a sex ratio (F/H) of 1.34. Of the participants, 39.8% were enrolled as undergraduates and 60.19% as graduate students. According to their scores on the Rheaume scale, the students were non-perfectionists (NP) in 21.4% of cases; moderately perfectionists (MP) in 70.38% of cases, and highly perfectionists (HP) in 8.25% of cases. Severe depression was objectified in 7.3% of the cases. Students living alone were less perfectionist (p=0.01). Perfectionism score was higher in depressed students (35 ± 6.34) versus (31.428 ± 6.37) with a statistically significant correlation ( p ≤ 0.001).It is true that perfectionism is an essential element for academic success. However, screening and prevention of depression are deemed necessary given its significant association with perfectionism.No significant relationships.


The Burnout syndrome occurs preferentially in individuals subjected to intense stress conditions. The nursing staff in Obstetrics Gynecology is an example of this.To assess the prevalence of Burnout and its determinants in the obstetrics gynecology service - Mahdia.We conducted an analytical cross-sectional study carried out with the medical and paramedical staff of the gynecology-obstetrics department of the Taher Sfar Mahdia hospital during a period of 3 months.We used a pre-established self-questionnaire containing 2 parts: a part exploring the socio-demographic data of the population and a psychometric part evaluating Burnt out using the “Maslach Burnout” scale inventory ”.Our sample consisted of 122 medical and paramedical personnel.The sex ratio was 4.3 (99/23), the mean age was 30.5 with values ranging from 25 to 55 years.Of the participants, 59 (48.3%) were single .Nine (7.4%) of the participants were smokers and 2 (1.6%) consumed alcohol.The majority of the population (96.7%) did not have a psychiatric history, 88 (80.3%) reported an organ history.A high level of burnout was noted in 64.8% of our population with 14.8% severe burnout. The presence of burnout was significantly associated with the consumption of psychoactive substances (p = 0.05) and professional rank (p = 0.04) .Nurses, residents and senior doctors werethose most at risk of developing burnout. It was also significantly related to the absence of other professional activities such as research (p = 0.05) and training continuing medical care (p = 0.05).Psychological intervention strategies with these suffering health promoters would be desirable.No significant relationships.


In total, 5817 cow milk samples were screened for AFM1 concentrations using the enzyme immunoassay assay (ELISA). For confirmation purposes of AFM1 concentration above the European Union maximum permitted level (MRL), ultra high-performance liquid chromatography with tandem mass spectrometry was performed. In 94.7% of milk samples, AFM1 levels were below the detection limit (LOD) of the ELISA test. For 3.47% of samples, the AFM1 was between the LOD and MRL values. Only 1.87% of all samples exceeded the MRL. The mean value of elevated AFM1 in different seasons ranged between 59.2 ng/kg (autumn 2017) and 387.8 ng/kg (autumn 2021). The highest incidences of positive AFM1 were determined in autumn and winter and the maximum (6.4%) was in winter 2019/2020. The largest percentage of positive samples (69.7%) was found in central Croatia. The estimated daily intakes for positive samples ranged between 0.17 and 2.82 ng/kg body weight/day. Risk assessment indicated a high level of concern during autumn and winter, especially for consumers of large amounts of milk.This study’s objective was to estimate the seasonal occurrence of aflatoxin M The most important toxin in milk and dairy products is aflatoxin M1 (AFM1 (AFB1) .Aspergillus species are genotoxic and carcinogenic substances that can suppress the immune system and cause hepatocellular carcinoma that can cause mortality in humans and livestock [1 into category 2B (possibly carcinogenic to humans) after it was found to have 10 times less carcinogenic potential than AFB1 [1 and it has been reclassified as a Group 1 substance [Control of aflatoxins in food and feed is one of the most important issues in ensuring food safety precisely because of their negative impact on human health, since they have the highest acute and chronic toxicity of all mycotoxins . The mosivestock ,5. The mivestock . Initialhan AFB1 . Howeverubstance .1 is both genotoxic and carcinogenic, it cannot be considered that there is a level of intake without any potential health hazards [1 in milk have been set. The prescribed maximum permitted levels of AFM1 in milk vary significantly from 50 ng/kg in the European Union [As AFM hazards . In ordean Union  to 250 nan Union  and 500 an Union ,12.Various factors, primarily environmental, affect the increase in aflatoxins, namely drought, elevated temperatures, pest damage, biological susceptibility of the host to infection, and the potential of fungi to produce aflatoxins . The occAspergillus [1 in dairy cow feed [1 concentrations in the milk and dairy products which was reported in countries such as Croatia [Tropical and subtropical regions are characterised by having climatic conditions with high temperatures and long periods of drought that favour the development growth of the toxigenic mould species ergillus ,15,16. Hergillus ,18. Such Croatia ,20, Serb Croatia , Kosovo  Croatia , and Mac Croatia .1 is a carcinogenic Group 1 compound, it is crucial to conduct constant control of its occurrence in milk and a thorough risk assessment in order to ensure the safety of milk and dairy products to protect consumer health. Therefore, the aim of this study was to estimate the occurrence of AFM1 in cow’s milk during different seasons in a five-year period in the territory of Croatia. Human exposure to AFM1 and a risk assessment with regard to milk consumption in Croatia was also conducted.Given the fact that AFMIn total, 5817 raw milk samples were collected in the period from winter 2016 to winter 2022. During that period, the laboratory received official samples of raw milk and raw milk from milk processing plants and farms sent within the self-control plans from all over Croatia. According to geographic information, milk samples were sorted by sampling area in four geographical regions in Croatia  as well g at 10 °C. The upper cream layer was removed by aspirating through a Pasteur pipette. Skimmed milk was used directly in the test (100 μL per well).Prior to analysis, milk samples were defrosted and centrifuged for 10 min at 3500× 1 concentrations were measured using a competitive enzyme immunoassay kit (ELISA) cat. No. R1121 . The test kit contained the following reagents: AFM1 standard solutions in milk buffer ; anti-aflatoxin M1 antibody (concentrate), conjugate , substrate/chromogen (tetramethylbenzidine), stop solution (1 N H2SO4), sample dilution buffer, conjugate, antibody dilution, and washing buffer for the preparation of 10 mM phosphate buffer  containing 0.05% Tween 20. Conjugate and antibody concentrates were diluted at 1:11 with the dilution buffer before analysis. Buffer salt was dissolved in 1 L distilled water and was ready for use for 4–6 weeks.AFM1 standard was purchased from Sigma-Aldrich . Aflatoxin B1 (AFB1) internal standard was used from another laboratory. The preparation of standard stock and working solutions was as previously described [The AFMescribed .TM HPLC were supplied by VICAM . Acetonitrile LC grade was purchased from Merck . Ammonium formate (97%) and formic acid (≥96%) were purchased from Sigma Aldrich Chemie GmbH . Nitrogen 5.0 and 5.5 were purchased from SOL spa . Ultrapure water was obtained using the Direct-Q® 5 UV Remote Water Purification System .Immunoaffinity columns (IAC) VICAM Afla M1®-Werke GmbH & Co., KG, Staufen, Germany) and centrifuge Rotanta 460R . Optical density was measured at 450 nm using Sunrise Absorbance Reader .Instrumentation used for the preparation of milk samples for the enzyme immunoassay assay (ELISA) method were: Vortex Genius 3 , Supelco vacuum manifold , centrifuge Rotanta 460R , and Nitrogen evaporation system N-EVAP® model 112 .For ultra high-performance liquid chromatography with tandem mass spectrometry analysis (UHPLC-MS/MS), samples were prepared with the following equipment: Iskra ultrasonic bath , IKA1 levels.An ultra high-performance liquid chromatographer with tandem mass spectrometer, UHPLC-MS/MS system consisting of UHPLC 1290 Infinity II and Triple Quad LC/MS 6470A mass spectrometer  was used for the analysis of samples with elevated AFM1 concentrations were measured using the ELISA screening method and for samples with concentrations above 50 ng/kg, a confirmation method using high-performance liquid chromatography with tandem mass spectrometry was used. Both analytical methods are accredited according to requirements of EN ISO/IEC 17025:2017.AFM1 was performed by the ELISA method according to the test kit instructions [1 at a known level (50 ng/kg). Quality control of the method results is checked every two years through participation in proficiency test organised by Test Veritas  and scored satisfactory results with z ≤ 2.Analysis of AFMructions . The metructions . Validatructions . The qua1 concentration was determined using the UHPLC-MS/MS system. The procedure includes steps of extraction and IAC clean-up. In brief, milk samples (100 mL) were defatted by centrifugation at 3000× g, 4 °C for 10 min. Purification using IAC columns was started by attached it to the vacuum manifold. A 10 g sample of defatted milk was passed through the column at a rate of 2.5 mL per minute. Columns were then washed twice with 10 mL of distilled water. AFM1 was eluted with 2.5 mL acetonitrile at a rate of 0.5 mL per minute. The sample eluate was collected in the tube and in this step, the internal standard AFB1 was added. The eluate was evaporated to dryness with nitrogen at 50 ± 5 °C and dissolved with 100 μL ultrapure water and 100 μL acetonitrile (vortexed and left in an ultrasonic bath for 5 min). Samples were further centrifuged at room temperature, for 10 min at 4500× g and filtered through 0.22 μm PVDF filters  prior to injection into the UHPLC-MS/MS system.For confirmation purposes, the AFMChromatographic separation of positive milk samples was achieved by isocratic elution using a Zorbax Eclipse Plus C18 Rapid Resolution HD, 3.0 × 50 mm, 1.8 µm particle size . The mobile phase for chromatography consisted of: A—5 mM ammonium formate in water with the addition of 0.1% formic acid; B—0.1% formic acid in acetonitrile. Chromatographic conditions were 60% mobile phase A and 40% mobile phase B, injection volume 7 μL, mobile phase flow 0.5 mL/min, run time 2 min, column temperature 40 °C.The triple-quad mass spectrometer consisted of a Dual AJS ESI ion source and was operated in positive polarity with the following settings: gas temperature 350 °C, gas flow 11 L/min, nebuliser 20 psi, sheath gas temperature 300 °C, sheath gas flow 6.4 L/min, capillary voltage 5000 V, nozzle voltage 0 V and EMV 250. A multiple-reaction monitoring approach (MRM) was used for the obtained data by selecting the two most intense ion transitions of the analyte .1 in milk and met the criteria for detecting residues of AFM1. The limit of detection (LOD) and limit of quantification (LOQ) were calculated as (ng/kg) LOD 2.8, LOQ 11.0. The chromatograms of spiked cow milk and positive milk sample are shown in The method was validated according to Commission Decision 2002/657/EC  and the previously described procedure . SatisfaThe laboratory participates in external quality control, proficiency tests (PT), organised also by Test Veritas . The results of analyses conducted on lyophilised milk during the years showed z scores in the acceptable range −2 ≤ z ≤ 2.1 concentrations through milk consumption was conducted by calculating the estimated daily intake (EDI) using the Equation [1 in milk (ng/kg), P is the milk meal consumption (milk g/day), and M is the mass of the individual (kg) for adults with a body weight (BW) of 70 kg. According to the survey on food consumption conducted on the general adult population in Croatia, the mean values of chronic milk consumption for consumers are 216.2 g/day and 2.96 g/kg BW/day. For consumers consuming large quantities of milk, i.e., the worst possible exposure scenario, the value of 95th percentile (P95) was used: 511.8 g/day; 7.27 g/kg BW/day [The exposure assessment based on determined AFMEquation :EDI =  > LOD.AFMropriate . In othe1 of 0.2 ng/kg bw day−1 was obtained by dividing the TD50 (dose threshold by body weight) with an uncertainty factor of 5000 and is equivalent to a risk level of 1 per 100,000 [The estimation of the hazard index (HI) was calculated by a comparison of EDI values with the tolerable daily intake (TDI); HI = EDI/TDI  which is 100,000 . The ris1 concentrations (ng/kg) were expressed as the number of samples (percent) in the categories: <LOD, LOD—49.9, ≥50. Positive AFM1 concentrations (≥50 ng/kg) were expressed as the arithmetic mean ± SEM, minimum and maximum value. The Shapiro–Wilk test was applied to determine the distribution of the data. Statistically significant differences (p < 0.05) between the same seasons between different years as well as between seasons in total were analysed by the Kruskal–Wallis test.Statistical calculations were performed using Small Stata 13.1 . AFM1 was analysed in a total of 5817 milk samples collected in Croatia during the five-year period between winter 2016/2017 and winter 2021/2022. Occurrence and distribution of AFM1 in raw cow milk samples collected in Croatia are shown in 1 concentrations were below the LOD value in 94.7% of milk samples. For 3.47% of samples, the AFM1 level was between the LOD and MRL values with a mean of 33.1 ± 7.47 ng/kg. Only 1.87% of all samples exceeded the MRL value of 50 ng/kg in the range of 50.3 ng/kg and the maximum value of 1100 ng/kg measured in autumn 2021. For total milk samples with concentrations above the LOD, the AFM1 mean was 61.4 ± 99.5 ng/kg. The mean values of elevated AFM1 concentrations (>50 ng/kg) ranged from the lowest 59.2 ng/kg (autumn 2017) to the highest 387.8 ng/kg obtained in autumn 2021. Elevated AFM1 values were not detected during spring 2017, 2018 and 2020, and summer 2018. The order of the mean positive values with respect to the total values for the seasons was (lowest to highest) spring > summer > winter > autumn.AFMp = 0.0313) in AFM1 concentrations for autumn seasons between the different years. However, no statistically significant differences (p > 0.05) were found for other three seasons between the years. There were also no significant differences between the seasons considering their total values throughout the study period.Statistical analysis showed significant differences  and the highest value of 1.15 ng/kg BW/day. The highest EDIs were calculated for autumn 2020 and 2021 (0.62 and 1.15 ng/kg BW/day) and winter 2021/2022 (0.62 ng/kg BW/day). EDI for total milk samples  with concentrations above LOD was 0.18 ng/kg BW/day.Based on the mean concentration of positive AFMassessed . The res1 between LOD and 49.9 ng/kg) and 2.82 ng/kg bw/day found also for autumn 2021.For consumers who consume large amounts of milk (95th percentile milk consumption), the highest EDI values were obtained in the range 0.24 ng/kg bw/day  for AFM1 values above the LOD, and further for winter 2016/2017 and 2017/2018, autumn 2017 and summer 2021. For all other seasons, HI was above 1, between 1.04 and 5.74. According to the highest EDIs calculated, the highest HI values, both for mean and for P95 percentile milk consumption, were determined for autumn 2020 and 2021, and winter 2021/2022: 3.10 and 7.71, 5.74 and 14.1, 3.1 and 7.62, respectively.Calculated HI values below 1 were found only for the mean value of milk samples with AFM1 concentrations was determined in autumn  and winter  periods with the highest incidence (6.4%) observed in winter 2019/2020. The obtained elevated AFM1 results in the autumn and winter months in the present study indicated the influence of the seasons on the occurrence of AFM1 contamination. This was particularly emphasised in the autumn months in which contamination of milk with AFM1 showed the highest mean values and statistically significant differences of means between years. This has previously been observed, i.e., the summer months show lower percentages of AFM1, while the winter months have a significantly higher incidence of contamination [1.In this study, only 1.87% of the total number of samples analysed in the five-year period had values exceeding the limits prescribed in the EU. The incidence of increased AFMmination ,32. SeasHowever, a significant impact on these results can be attributed to climatic factors or climatic extremes that affect the occurrence and growth of toxic moulds before and during maize harvest, or to the elevated temperatures and droughts present in all seasons in two regions, central and southern Croatia, especially central Croatia. Namely, the European continent, just as the rest of the world, is exposed to significant climate changes, i.e., deviations in temperature and precipitation from average seasonal values due to anthropogenic activity . All EU The Croatian Meteorological and Hydrological Service monitors the climatic characteristics of air temperature and precipitation in Croatia on the basis of average monthly, seasonal, and annual values and reports them as a representation of deviations from the multi-year average for the reference period 1981–2010. The summary annual reports showed that according to measured temperatures, the years 2017, 2018 and 2019 were: 2017, extremely warm in 85% of the territory of Croatia, and very warm in the remaining 15%; 2018, extremely warm in the entire territory; 2019, extremely warm in 50% of the territory and very warm for the remaining 50% ,38,39.1 in cereals, which was seen in the largest number of positive milk samples (38.5%) at the annual level. Spring 2019 (March–May), especially May, was characterised by a rainy to the very rainy state of precipitation, i.e., extremely rainy in central and southern Croatia in relation to the multi-year average (1981–2010) for Croatia. After May, extremely warm weather was recorded in June 2019 in central and eastern Croatia, with a temperature increase of 3.4 to 4.6 °C compared with average temperatures [Climatic characteristics recorded in 2019 were suitable for the development of mould and the synthesis of AFBeratures . In addiAn increased number of positive samples were also found in the autumn and winter of 2021. The characteristics of the climatic conditions were increased temperatures in January and February in central and eastern Croatia with 1.8 to 3.9 °C higher temperatures than the average values and a heavier rainy season in January 2021. April and May 2021 were characterised by cold weather in central Croatia and very cold in eastern Croatia. May was very rainy in central Croatia. Extremely warm weather was recorded in June and July throughout Croatia and extremely dry in June. Furthermore, autumn September was warm and dry in central and eastern Croatia .1, resulting in contamination of cereals and dairy cow feed. A study conducted on corn samples during 2013 in Croatia (referred to the genus 2012) showed AFB1 concentrations higher than maximal permissible level in 28.8% of the samples. Therefore, it was concluded that higher AFB1 concentrations in grain mixtures and feed for cows could be attributed to a substantial AFB1 corn contamination determined in 2013 [1 contamination, high levels of AFM1 in milk were measured in Croatia [1 levels exceeding the EU MRL were measured in 45.9% and 35.4% of milk samples collected in February and March 2013 in eastern Croatia [1 levels in the present study, a higher frequency of elevated AFM1 concentrations in milk samples was recorded in central Croatia. A subsequent study in Croatian in 2014 showed a reduction in feed contamination with AFB1, i.e., lower concentrations of AFM1 (only 2.37% of milk samples exceeded EU MRL) were found in winter in eastern Croatia [1 concentrations in Croatia showed a frequency of positive milk samples of 0.3% and 1.1% in spring and autumn 2016 [Extreme weather conditions, warm weather, and prolonged periods of drought, especially during maize growth and harvesting, were also recorded in previous years in Croatia, i.e., 2012. Such weather conditions facilitate fungal infection and stimulate the production of AFB in 2013 . As a co Croatia . This re Croatia  and furtumn 2016 .1 appearance in milk in the present study were also significantly lower than the results of different studies carried out in the period 2013–2018 in the neighbouring country of Serbia. A study conducted in the period 2013–2014 showed that 56.3% of raw milk samples exceeded EU MRL and the mean AFM1 was 358 ng/kg in winter and 375 ng/kg in spring [1 levels exceeding the EU limits, with mean values between 153 and 353 ng/kg and a maximum of 5078 ng/kg measured in 2013 [The results of the frequency of AFMn spring . Another in 2013 .In Serbia during the period 2015–2018, 46.2% of raw milk samples exceeded the EU MRL, with the highest frequency of 65.4% and maximal mean level of 220 ng/kg in autumn . Another1 concentrations were between 10.3 and 12.4 ng/kg, and concentrations exceeding the EU MRL were detected in only 0.2% of samples [1 concentrations in the period 2014–2020 showed a frequency of positive milk samples of 0.86%, while in 2015 the occurrence was 1.5% [A significantly better situation was recorded in the neighbouring Italy during the period 2013–2018 when 31,702 milk samples were analysed and mean AFM samples . In addiwas 1.5% .1 exceeded the EU MRL in a total of 5.88% milk samples, and it was concluded that milk collected during 2019 had higher AFM1 levels with a maximal concentration of 217 ng/kg [1 in milk compared with 2020.In a recent study from Albania conducted for the period 2019–2020, AFM17 ng/kg . These r1 in tropical and subtropical countries of the world, the occurrence of AFM1 in milk is a constant phenomenon in these countries. Successive studies from Pakistan showed a significant incidence of raw milk contamination with AFM1 in both summer  and winter season  [1 (> 50 ng/kg) in milk are Pakistan 53% [1 in milk in countries whose legislation prescribes an MRL of 500 ng/kg showed an incidence above 500 ng/kg were Brazil 38% [Given the climatic predispositions for the development of toxigenic moulds and the production of AFB0%, 29%) ,48. Studstan 53% , India 4stan 53% , Banglad9%) [1 >  ng/kg instan 53% , South Astan 53% , Ecuadorstan 53% . The incazil 38% , Pakistaazil 38% ,57, and azil 38% .1 of 1100 ng/kg was measured in Central Croatia during September 2021 which suggests the usage of a highly contaminated feedstuff in the diet of dairy cows on that particular individual farm. Compared with the established value in a recent study from Pakistan, an extremely high mean AFM1 level of 1535.0 ng/kg was determined with a maximal value of 7460.7 ng/kg [In this study, the highest AFM.7 ng/kg . In addi.7 ng/kg .1 concentrations in corn or feed for dairy cows in Croatia for the period in which this study was conducted. According to previous studies, it can be concluded that the highest contribution to AFM1 in milk is due to contaminated corn, which is usually represented in the amount of 20–30% in feed concentrate used in the winter months for diet of dairy cow [There are no literature data on the monitoring of AFBairy cow ,58. Thisairy cow .1 in all age groups of consumers are the food categories “liquid milk” and “fermented milk products” [1 allows scientific analysis to assess the severity and likelihood of adverse effects on human health through milk consumption, thus ensuring a link between possible hazards in the food chain and associated risks to human health. There is no consensus on the tolerable daily intake (TDI) for aflatoxins at the European Union level and therefore TDI is not determined for AFB1 or AFM1 [According to EFSA, the main contributors to the total average exposure to AFMroducts” . Assessi or AFM1 . Therefo or AFM1 .1 milk samples and the calculated HI index are presented in 1 by season were determined for the autumn periods 2020 and 2021 and winter 2021/2022 according to the highest mean values of elevated AFM1 concentrations. The highest EDI of 1.15 ng/kg BW/day (5.74 ng/kg BW/day for 95th percentile milk consumption) was found in autumn 2021. Such high exposures were calculated taking into account only values above 50 ng/kg, which is in itself the worst-case scenario.In this study, the EDIs of positive AFM1 (ng/kg BW per day) for mean values and the 95th percentile dietary exposure between 0.04 and 0.06 ng/kg BW/day and 0.13 and 0.16 ng/kg BW/day in the total adult population of the European Union [1 concentrations above the LOD are taken into account in this study, it can be concluded that a higher exposure of the adult population was found (0.18 ng/kg BW/day) compared with the average European values.EFSA obtained chronic dietary exposure to AFMan Union . Compare1 conducted in Serbia have shown different results for adults, respectively, 0.503–1.420 ng/kg BW/day [Different studies regarding the daily exposure to AFMg BW/day , 0.16–0.g BW/day , for stug BW/day , 0.062–0g BW/day . For theg BW/day . In a Brg BW/day . For theg BW/day .1 in studies conducted in Pakistan also varied by season, i.e., 0.22–5.45 ng/kg/day during different seasons [1 exposure for raw milk and processed milk (UHT and pasteurised) for consumers was 11.9 and 4.5 ng/kg BW/day, respectively [The EDI obtained in India showed a range between 0.034 and 1.036 ng/kg BW/day depending on three agro-climatic zones [ seasons , 0.47–0. seasons . A recenectively .1 between LOD and 49.9 ng/kg and also for the total mean for all quantified AFM1 values above the LOD for all seasons, which actually means that the average exposure to AFM1 in the observed five-year period does not pose a risk. However, if the concentrations are viewed by season and expressed according to positive AFM1 values, the determined HIs are significantly high (H > 1) and represent a health concern. In most seasons, HI was between 0.88 and 1.72. HI values were found to increase with seasonal positive mean AFM1 levels and EDIs and the highest HIs were calculated in autumn 2020 and 2021, and winter 2021/2022: 3.10 and 7.71, 5.74 and 14.1, and 3.1 and 7.62, respectively. The results showed that consumers who consume large amounts of milk (95th percentile milk consumption) were particularly exposed. It is known that chronic exposure to high concentrations of AFM1 increases the risk of liver cancer [In this study, the calculated HI < 1 was determined for mean milk samples with AFMr cancer .Similar results for HI were presented in Serbia for adults (over 26 years), in the range of 0.84–1.16 and values higher than 1 were found for females . In a re1 in the period when dairy cow receive substitute feed in autumn and winter. Given the influence of the seasons, it was found that during the autumn months AFM1 showed the highest mean values and statistically significant differences of means between years. Overall, the largest percentage of positive samples was found in central Croatia (69.7%). The obtained result is not surprising considering the climatic extremities, i.e., elevated temperatures and dry period to which region is exposed throughout all seasons. However, rates of milk contamination were not as high as in the crisis period during 2013–2014. Overall, according to the results obtained in this study, it can be concluded that the previous crisis has affected the overall improvement of the aflatoxins control system. This was particularly evident through increased official controls of AFB1 in feed or AFM1 in milk. In this way, there was a significant reduction of these natural contaminants in the food chain, thus ensuring the safety of milk and milk products in Croatia.The presented results showed that the described weather conditions of extreme droughts contributed to the development of toxigenic moulds and influenced the increased frequency of milk contamination with AFM1 dietary exposure from raw cow milk indicates a high level of concern during autumn and winter from the public health perspective. The risk is particularly pronounced for consumers who consume large amounts of milk (95th percentile milk consumption). Given the regional exposure, it can be concluded that the population in central Croatia is more exposed to health risks due to AFM1 ingestion through milk consumption.The risk assessment of AFM1 exposure due to the consumption of higher amounts of milk and dairy products.As climate change shows irreversible change and will increasingly affect feed production, there remains room for further improvements in feed processing and storage processes to reduce mycotoxin contamination during critical periods in autumn and winter. Future studies should focus on infants and young children, as this is the population considered most sensitive to AFM