Naegleria species. Therefore, the presence and prevalence of Naegleria species in the water bodies of North-Western Province were determined by molecular characterization and phylogenetic analysis in this study.The inland freshwater bodies in the North-Western Province of Sri Lanka have ideal environmental conditions for the Escherichia coli. Enflagellation test positive isolates were subjected to DNA extraction and polymerase chain reaction using genus and species-specific primers targeting the internal transcribed spacer region (ITS) and Mp2CL5 gene. Phylogenetic analysis was performed using Bayesian and maximum likelihood (ML) methods.A total of 104 water bodies were selected from Kurunegala and Puttalam districts in the North-Western Province of Sri Lanka. Mean turbidity, pH, and temperature were recorded in each water body from three selected site. Centrifuged samples were cultured on non-nutrient agar plates with Naegleria species and N. fowleri in the study area were 23.07% and 1.92%. The prevalence of Naegleria species and the physicochemical parameters of the water bodies showed no significant correlation. Bayesian analysis of the ITS region revealed the Naegleria Sri Lankan (SL) isolates 1, 3, and 4 in a single clade separated from the 2 and 5. Furthermore, Bayesian analysis identified isolates 2 and 5 in the same clade with Naegleria sp. samples and N. Philippinensis forming a sister clade. However, in the ML tree, all isolates were in the same clade with Naegleria sp. samples and N. Philippinensis.The prevalence of N. fowleri from Sri Lanka. Based on Bayesian analysis, SL isolates 2 and 5 form a separate clade from 1, 3, and 4. However, in ML analysis, all isolates are grouped in one clade with Naegleria sp. samples and N. philippinensis. Further investigations are required to confirm these findings.The present study reports the first isolation of pathogenic  Naegleria is a group of free-living amoebae (FLA) with more than 47 species [Naegleria fowleri is the only species in this genus that is known to cause human disease. Trophozoites of N. fowleri can penetrate the cribriform plate and cause fulminant and primary amoebic meningoencephalitis (PAM) in humans. This disease is acquired while swimming, diving, or total submersion in water bodies contaminated with the infective stage of N. fowleri [The genus  species . Naegler fowleri .Naegleria species can be isolated from soil, air, and natural, industrial, and domestic water systems [Naegleria species varies from 23% to 89%, depending on the geographic location [Naegleria spp. in Asia, including Thailand, China, and India [ systems –5. The glocation . Severalnd India ,7–10.Naegleria species from Sri Lanka. However, N. fowleri is not reported in Sri Lanka [Naegleria species. These water bodies are used frequently by the local people for their daily needs. Therefore, we investigated the presence of Naegleria species in the North-Western Province and analyzed their molecular characteristics. Furthermore, the present study reports the first isolation of N. fowleri from Sri Lanka.Only two previous studies have reported the isolation of ri Lanka ,12. Thes2 [The present study was carried out in North-Western Province of Sri Lanka, located in the dry zone, and consisted of Kurunegala and Puttalam administrative districts. Approximately there are more than 6,000 water bodies in North-Western Province ,14. The 2 , with 762 .The sample size was decided by the formula given by Lachenbruch et al., 1991 . The perDue to the seasonal monsoon rain in Sri Lanka, samples were collected for a long period, from April 2013 to September 2018. Each water body had several entryways. Based on animal and human contact, three different sites in a water body were selected for the sample collection. The first site was frequently used by local people, the second site was frequently used by local livestock, and the third site was minimally used by either humans or animals. Two water samples were collected from each site separately: one from the surface water and the other from deep water. Water samples were collected directly into sterile universal glass containers. The surface water samples were taken approximately 0.5 m away from the bank. The deep samples were taken approximately 1 m deep from the water level. Capped containers were dipped underwater then filled and were closed at the same deep level. Containers were labelled immediately after the collection, and the water samples were transported to the laboratory within 24 h of collection.Naegleria spp. Altogether 624 samples were collected from 104 selected water bodies. Similarly, 624 water samples were collected from each site to analyze the physicochemical parameters in the field.A total number of six water samples were collected (two samples from each of the three sites in one water body) from each water body to identify Escherichia coli (NCTC-10418) enriched agar plates as described by Ash and Orihel, (1987) [®). The examination of plates was continued for FLA up to 7 days before discarding.Each sample was well-shaken and poured into 15 ml conical tubes. The tubes were centrifuged (2000 rpm for 2 min) and the sediments were used for inoculation. Cultures were inoculated on  NCTC-104 enriched(Leitz Diavert®). If enflagellation was not observed immediately, the solvents were incubated for 2 hours at 37°C [Scrapings from FLA positive culture plates were mixed with 1 ml of distilled water and incubated at 37°C for 30 min. Wet smears were prepared to observe enflagellation (transformation of trophozoites into pear-shaped bi-flagellates or multi flagellates)  under an at 37°C , and samNaegleria cysts and flagellates were harvested from culture plates positive for enflagellation test and examined by a light microscope (magnification x1000). The trichrome staining technique [Naegleria trophozoites, cysts, and flagellate forms were observed and the length of the trophozoites and flagellate and diameters of the cysts were measured [echnique  was usedmeasured .® Genomic DNA Kit according to the manufacturer’s guidelines.The enflagellation test-positive culture plates were selected for DNA extraction. The surface of the agar plate was scraped with a sterile glass slide and washed thoroughly with 1.5 ml of distilled water. The washing was collected into a conical tube and centrifuged at 3000 rpm for 3 min. After that, 200 μl of the resulting deposit was taken for the DNA extraction using a PureLinkNaegleria genus-specific primers 1 and 2. The primers 1 and 2 amplified portions of the internal transcribed spacer region (ITS). The primer sequences, amplified regions, and amplicon sizes are given in 2, 2.5 mM deoxynucleotide triphosphate (dNTP), 10 pmol primers, and 0.5 μl Taq DNA polymerase (5 u/μl), a total volume of 25 μl. PCR conditions for primers 1 and 2 as follows; initial denaturation at 94°C for 3 min, 35 cycles of denaturation at 94°C for 30 s, annealing at 55°C for 30 s, extension at 72°C for 1 min and final extension step at 72°C for 5 min.DNA of each extracted sample was amplified using two Naegleria genus-specific primers were then subjected to PCR using nested PCR primers as shown in N. fowleri species-specific primers). These primers amplified the Mp2Cl5 membrane protein gene of N. fowleri.DNA samples that were positive for Primer 3 was used for the nested PCR. Similar concentrations mentioned for the genus-specific PCR mixture were used, and the first PCR was carried out according to the conditions given in Sifuentes et al., 2014 . The nesPCR products were purified (PureLink™ Genomic DNA Mini Kit) and sequenced using the PCR primers as sequencing primers in Applied Biosystem 3130 automated sequencer; Macrogen, Korea.Naegleria spp. available in the NCBI GenBank were obtained using ClustalW v2.0. Default gap penalties were given.Sequences were manually edited using BioEdit v7.0.5.3 . The seqBayesian inference was carried out in MrBayes  for ITS2N. fowleri sequences, and only the sequence alignment was carried out using MEGA v.7.0.26.Only one sequence was available for the Mp2CL5 gene in the GenBank. Therefore, a phylogenetic tree was not constructed for the A portable digital turbidity meter (WGZ-1B), pH meter (Yuelong), and thermometer (TP300) were used to measure the physicochemical parameters in the water. The mean turbidity in Nephelometric Turbidity Units (NTU), pH, and water temperature (°C) of each sampling site were measured and recorded at the same time of sample collection.MINITAB (v.17)  softwareOf the total 624 samples, 320 (51.28%) were tested positive for FLA by culture . Out of The amoebae, cysts, and flagellate forms were identified according to the morphological features given in Cheesbrough (1981)  Fig 1A . The troThe trichrome staining visualized nuclei in red and the cytoplasm in green colour. The length of the trophozoites was approximately 20–22 μm . The celOut of the 123 enflagellation positive samples, 17 were positive for primer 1  and 7 weNaegleria sp.  and 99.11% similarity with N. philippinensis .Bayesian tree constructed with 24 taxa is shown in Naegleria species  and 98.81% similarity with N. philippinensis .Isolate 2 showed 98.81% similarity with Naegleria species  and 98.69% similarity with N. philippinensis .Isolate 5 showed 98.69% similarity with Naegleria Sri Lankan (SL) isolates 1, 3, and 4 in a single clade separated from the Naegleria SL isolates 2 and 5. Furthermore, Bayesian analysis identified isolates 2 and 5 in the same clade with Naegleria sp. samples and N. Philippinensis forming a sister clade  in the BLAST search and the sequence alignment.The Naegleria species in the surface water and deep water were 4.48% and 3.20% respectively. The total prevalence of Naegleria spp. in the study area was 23.07%. The N. fowleri was detected in Periyakulama wewa  and Dignnewa wewa . The prevalence of N. fowleri was 1.92% in the study area.The prevalence of st, 2nd, and 3rd). The mean temperature and pH of surface and deep water samples of the 1st site were significantly higher than the 2nd and 3rd site samples (P<0.05).The temperature, pH, and turbidity of water samples varied within 25–39°C, 7.10–6.82 pH, and 44–723 NTU respectively . TemperaNaegleria species present in the dry zone of North-Western Province. In the present study, the amoebae, cysts, and flagellate forms were observed, and the bi-flagellates were observed with a typical locomotion pattern. Among 123 enflagellation test positive samples, only 24 were positive for Naegleria by PCR. This difference could be due to false-positive results of the enflagellation test. A previous study confirms the nonspecificity of enflagellation test in the identification of the genus Naegleria [This study focus on the detection and identification of aegleria .Naegleria species varies from 28% to 89% [Naegleria species in the present study area is 23.07%. A similar prevalence rate to the Naegleria species in the present study was reported in Egyptian aquatic environments (24.6%) [Naegleria species was reported in a study conducted in Taiwan (4%) [The global prevalence of % to 89% . The ove (24.6%) . In contN. fowleri identified in two water bodies in Kurunegla and Puttalam districts in this study is 1.92%. A meta-analysis conducted in 2020 identified the global prevalence of N. fowleri as 23.27% [N. fowleri [N. fowleri is reported in Sri Lanka. However, according to the Sri Lankan Annual Health Bulletin of 2016 [The prevalence of s 23.27% . There a fowleri . From 19 fowleri . To date of 2016 , approxiNaegleria species isolated from this study did not significantly confine to any specific sampling site (p>0.05). We identified a higher prevalence of Naegleria in surface water (4.48%) than in the deep-water samples (3.20%). However, there was no statistical significance in the reported differences (p>0.05). A previous study conducted in Sri Lanka identified Naegleria thrive more significantly in surface water than in deep-water [Naegleria in surface water [Naegleria in surface water, compared to the present study, was reported in India (34.5%), Iran (15%), and Japan (68.7%) [of Naegleria species in deep water [N. fowleri was also isolated in deep wells [ep-water . Two difce water ,41. A hind Japan 8.7% [6,4 (68.7%) ,43. Prevep water –46. N. fep wells , the gro water 4.% than inep wells .Naegleria clade containing all SL isolates and N. philippinensis Click here for additional data file.S2 FigLanes L: 100 bp ladder; NC: Negative control; PC: Positive control; each sample is labelled by incorporating location, site, and depth of the collected sample. Among these samples, 77/1D and 78/3S show positive results.(TIF)Click here for additional data file.S3 FigNaegleria SL isolates 1, 3, and 4 are in the same clade with N. philippinensis. Naegleria SL isolates 2 and 4 are in a separate clade from SL isolates 1, 3, and 4.Numbers above the nodes indicate bootstrap values (>50%). Scale bar represents 0.05 nucleotide divergence. (TIF)Click here for additional data file.S1 Table(TIF)Click here for additional data file.


Cediranib, an oral anti-angiogenic VEGFR 1-3 inhibitor, was studied at a daily dose of 20 mg in combination with platinum-based chemotherapy and as maintenance in a randomised trial in patients with first relapse of ‘platinum-sensitive’ ovarian cancer and has been shown to improve progression-free survival (PFS).NCT00532194) was an international three-arm, double-blind, placebo-controlled randomised trial. Between December 2007 and December 2011, 456 women were randomised, using stratification, to receive either chemotherapy with placebo throughout ; chemotherapy with concurrent cediranib, followed by maintenance placebo ; or chemotherapy with concurrent cediranib, followed by maintenance cediranib . Due to an enforced redesign of the trial in September 2011, the primary endpoint became PFS between arms A and C which we have previously published, and the overall survival (OS) was defined as a secondary endpoint, which is reported here.ICON6  in favour of arm C. There was strong evidence of a departure from the assumption of non-proportionality using the Grambsch–Therneau test (P = 0.0031), making the HR difficult to interpret. Consequently, the restricted mean survival time (RMST) was used and the estimated difference over 6 years by the RMST was 4.8 months (95% CI: −0.09 to 9.74 months).After a median follow-up of 25.6 months, strong evidence of an effect of concurrent plus maintenance cediranib on PFS was observed [hazard ratio (HR) 0.56, 95% confidence interval (CI) 0.44-0.72, Although a statistically significant difference in time to progression was seen, the enforced curtailment in recruitment meant that the secondary analysis of OS was underpowered. The relative reduction in the risk of death of 14% risk of death was not conventionally statistically significant, but this improvement and the increase in the mean survival time in this analysis suggest that cediranib may have worthwhile activity in the treatment of recurrent ovarian cancer and that further research should be undertaken. •Cediranib is an oral VEGF receptor kinase inhibitor and ICON6 explored its activity in recurrent ovarian cancer.•In a randomised trial cediranib with chemotherapy and as maintenance significantly prolonged PFS.•Cessation of cediranib supply led to a reduction in sample size and OS was underpowered.•A mature survival analysis showed a non-significant increase in the median and Restricted Mean Survival Time (RMST) with cediranib.•There was a clinical benefit of cediranib but further research is needed to determine its role in recurrent ovarian cancer. Ovarian cancer is the leading cause of death from gynaecological tumours in high-income countries. Most women present with advanced disease and in more than 75% of these patients the disease recurs after frontline treatment. Many have disease that will respond again to treatment, usually with platinum-based chemotherapy, but the response duration becomes shorter with each subsequent therapy, and the disease in these patients is almost invariably fatal.7NCT00532194) developed through the GCIG (Gynecologic Cancer InterGroup), and led by the MRC Clinical Trials Unit at University College London (UCL).Cediranib (AZD2171) is an oral VEGF receptor (VEGFR 1-3) and c-Kit,,P < 0.0001). Here we report the overall survival (OS) after extended follow-up and exploratory endpoints. Thirty patients were treated at the higher 30 mg dose, but the primary analysis and this OS update focus on the 20 mg dose.The ICON6 trial opened in December 2007. In October 2011, when 380 patients had been randomised, AstraZeneca announced a cessation in the manufacture of cediranib due to disappointing results from trials in colorectal cancer, non-small-cell lung carcinoma and glioblastoma.Women from 62 centres in the UK, Canada, Australia, New Zealand and Spain with recurrent ovarian, fallopian tube or primary peritoneal cancer requiring further platinum-based chemotherapy ≥6 months after completing first-line chemotherapy were entered into ICON6. The inclusion and exclusion criteria have been previously described.,Six cycles of three-weekly chemotherapy were planned, but the maintenance phase could begin after a minimum of four cycles if patients were unable to complete six cycles. Carboplatin with either paclitaxel or gemcitabine was the recommended treatment but carboplatin monotherapy or cisplatin, if combination regimens could not be given, were allowed.,,Trial drug, cediranib or placebo, was started with chemotherapy and continued to progression or unacceptable toxicity. An initial safety phase employed a single daily dose of 30 mg. Following review of the first 30 patients in November 2008,,,https://doi.org/10.1016/j.esmoop.2020.100043) and the protocol is available at http://www.icon6.org/protocol.The revised sample size, fully described in the original publication, required 440 patients to be randomised to the 20 mg dose. In order to maximise the limited power, the primary comparison was revised from the two pairwise arm A versus arm B versus arm C comparisons to a single pairwise arm A versus arm C comparison. This decision was taken as it was considered the most appropriate comparison to target given the emerging data for concurrent and maintenance bevacizumab.Lancet by Ledermann et al.At the time of the primary outcome reported in the The revised Statistical Analysis Plan did not specify when the secondary outcome measure of OS would be analysed. However, given the reduced power, the analysis was delayed until fewer than 10% of patients were still alive. Following the reporting of the primary endpoint, the log-rank (LR) test was used as the primary test of an overall difference between Kaplan–Meier curves. A pre-specified plan to address the proportionality of hazards was made, due to the difficulty of interpreting the HR in the presence of time-dependent treatment effects. The presence of non-proportional hazards was to be assessed using the Grambsch–Therneau test.In addition, the time to first subsequent treatment (TFST) was measured as an exploratory outcome given its emerging clinical relevance and the fact that patients could continue trial drug beyond documented disease progression.As reported previously, all three treatment groups were balanced with respect to their pre-treatment demographic characteristics.P = 0.24), but there was strong evidence of a departure from the assumption of non-proportionality using the Grambsch–Therneau test, P = 0.0031.https://doi.org/10.1016/j.esmoop.2020.100043.Median follow-up, using the inverse Kaplan–Meier method, was 7 years at 83.7 months in arms A and C with a database cut-off date of 1 October 2018. At this point 106/118 (90%) deaths in arm A and 149/164 (91%) in arm C had occurred. The median survival in arm A was 19.9 months [95% confidence interval (CI): 17.4-26.5] and in arm C 27.3 months (24.8-33.0), a difference of 7.4 months. The HR estimate was 0.86 with a 95% CI of 0.67-1.11. The survival differences in the Kaplan–Meier plot  appear tP value = 0.0014 (Cediranib as a maintenance treatment prolonged the median TFST compared with placebo with a difference in RMST of 5.2 months from 13.2 to 18.5 months. An HR of 0.64 (0.49-0.85) was observed, illustrating that patients on cediranib were delayed going onto a subsequent treatment, LR = 0.0014 . CediranNo additional toxicity has been reported since the detailed primary results of the primary outcome, reported in 2016. The median time on trial drug for arm A was 8.2 months and arm C, 7.6 months. A significant number of patients continued on trial drug beyond 12 months, noticeably in the maintenance arm compared with placebo (26% versus 19%) and this difference persisted at 18 months (11% versus 5%). One patient on the maintenance arm continued cediranib treatment for 5.4 years before developing progressive disease. Three patients (2.5%) on arm A and six patients (3.7%) on arm C never started any trial treatment.In those patients who received trial drug for at least 12 months [22 (19%) in arm A and 42 (26%) in arm C], and concentrating on the toxicity events occurring after 12 months, we observed an increased incidence of the four most common side-effects in patients taking cediranib. Grade 3 fatigue occurred in 5% of patients (one patient) in arm A but in 14% (six patients) in arm C. Grade 2 diarrhoea was reported by 14% (three) of patients in arm A but by 50% (21 patients) in arm C. Grade 3 diarrhoea was also more common in patients on cediranib compared with placebo, with 5% (one patient) in arm A versus 24% (10 patients) in arm C. Hypertension generally was more common; at grade 2.18% (four patients) versus 38% (16 patients) and grade 3.5% (1 patient) versus 10% (4 patients). Grade 2 nausea was less common in arm A  than arm C . This slight increase was also mirrored in grade 3 nausea with 5% (1 patient) versus 10% (four) for patients on cediranib.The only incidents of grade 4 or above were experienced by <5% of patients; these were one grade 4 thrombosis and one intra-operative injury, both in arm A.Of the 26% (42/164) of patients in arm C who were on trial drug at 1 year, 12% (5/42) stopped due to toxicity rather than progression.We report the final survival analysis of women receiving platinum-based chemotherapy with or without placebo-controlled concurrent or concurrent/maintenance cediranib for platinum-sensitive ovarian cancer treated at first relapse. Although the primary analysis of ICON6 showed a significant improvement in PFS with cediranib, this did not lead to a statistically significant survival benefit. This interim comparison of cediranib with chemotherapy and as maintenance reported a 5.3-month median difference in OS. Cediranib or placebo was taken for a median of 8.3 (95% CI: 7.5-9.2) months in Arm B and 8.5 (95% CI: 6.4-9.8) in arm C.Before the definitive OS analysis reported here, a second interim OS analysis occurred following a request for an update from the Committee for Medicinal Products for Human Use (CHMP) at the EMA in November 2014. The updated analysis for the EMA took place after 74% of deaths had occurred with a data cut-off of 1 November 2014. The HR at this point in time was 0.84 (95% CI: 0.63-1.11).,,,,P = 0.056).The clinical behaviour of the vascular targeting drug, cediranib, may be similar to that of other anti-angiogenic drugs, notably bevacizumab, which when given with chemotherapy and then as maintenance demonstrated improvements in PFS without significant OS gains in first-line or recurrent ovarian cancer treatment.,,The OS of patients in the ICON6 placebo arm was 19.9 months. This is lower than other comparable trials using platinum-based combination therapy for recurrent ovarian cancer. In the OCEANS trial the median OS for the placebo arm was 35.2 months and in the CALYPSO trial it was 30.7 months and 33.0 months in the chemotherapy arms with carboplatin and either liposomal doxorubicin or paclitaxel.https://doi.org/10.1016/j.esmoop.2020.100043), respectively, resembling the differences seen with placebo or bevacizumab in GOG-0218, which were 41.1 and 43.4 months, respectively.Ninety per cent of patients participating in ICON6 underwent third-line treatment; a similar percentage of post-progression treatments to that reported in the OCEANS trial . The results recently reported showed that adding cediranib to olaparib improves anti-tumour activity, but the combination is not superior to chemotherapy.NCT03278717).All of the published trials of oral VEGFR inhibitors in ovarian cancer have shown a benefit in PFS, yet none has been licensed for treatment of recurrent ovarian cancer.Early management of toxicity is important if patients are to remain on the drug for a prolonged period. Even so, after 12 months of therapy there was a higher incidence of fatigue, diarrhoea and hypertension compared with the placebo so that careful monitoring of patients is required. Of the 26% (42/164) of patients in arm C who were on trial drug for 1 year only, 12% (5/42) stopped treatment due to toxicity. However, in spite of these toxicities there was no detrimental effect on quality of life at 1 year.


The increased morbidity and mortality due to type 2 diabetes can be partly due to its delayed diagnosis. In developing countries, the cost and unavailability of conventional screening methods can be a setback. Use of random blood glucose (RBG) may be beneficial in testing large numbers at a low cost and in a short time in identifying persons at risk of developing diabetes. In this analysis, we aim to derive the values of RBG corresponding to the cut-off values of glycosylated hemoglobin (HbA1c) used to define prediabetes and diabetes.Based on their risk profile of developing diabetes, a total of 2835 individuals were screened for a large diabetes prevention study. They were subjected to HbA1c testing to diagnose prediabetes and diabetes. Random capillary blood glucose was also performed. Correlation of RBG with HbA1c was computed using multiple linear regression equation. The optimal cut-off value for RBG corresponding to HbA1c value of 5.7% (39 mmol/mol), and ≥ 6.5% (48 mmol/mol) were computed using the receiver operating curve (ROC). Diagnostic accuracy was assessed from the area under the curve (AUC) and by using the Youden’s index.RBG showed significant correlation with HbA1c . Using the ROC analysis, a RBG cut-off value of 140.5 mg/dl (7.8 mmol/L) corresponding to an HbA1c value of 6.5% (48mmol/mol) was derived. A cut-off value could not be derived for HbA1c of 5.7% (39 mmol/mol) since the specificity and sensitivity for identifying prediabetes were low.Use of a capillary RBG value was found to be a simple procedure. The derived RBG cut-off value will aid in identifying people with undiagnosed diabetes. This preliminary screening will reduce the number to undergo more cumbersome and invasive diagnostic testing. Type 2 diabetes (T2D) remains undiagnosed for many years in large number of persons living in developing countries . The costh February 2012.This is a post – hoc analysis of the primary prevention trial done in South India . The study design, recruitment strategy and the outcome of screening were described previously ,11. BrieRecruitment of study participants was conducted between April 2012 and September 2013. From the 15 study sites a total of 6030 persons were identified to undergo initial prescreening using a non-invasive questionnaire method. At the prescreening, 2835 individuals were identified as having ≥ 3 risk factors for diabetes and were selected for the next stage of screening using HbA1c testing. The HbA1c test was performed using a point-of-care device (Bio-Rad in2it™ (I) System). This instrument has been standardized to the recommendations of the Diabetes Control and Complications Trial and certified by the National Glycohemoglobin Standardization Program. The HbA1c values obtained by the point-of-care analyzer and immunoturbidimetric assay used in our laboratory  yielded a significant correlation .Concurrently, capillary random plasma glucose was also measured using a glucometer , calibrated to infer venous plasma glucose values . GlucoseCorrelation of RBG with HbA1c was computed using multiple linear regression equation corrected for age and gender. The optimal cut-off values for RBG corresponding to HbA1c values of 5.7% (39 mmol/mol), (cut-off for prediabetes) and ≥ 6.5% (48 mmol/mol), (cut-off for diagnosing diabetes) were computed using the receiver operating characteristic curve (ROC). The sensitivity and specificity of RBG for detecting diabetes and prediabetes based on HbA1c were calculated by the area under the curve (AUC). Diagnostic accuracy was calculated using the Youden’s index.Prescreening was conducted for a total of 6030 persons, to verify eligibility for the prevention trial. Among them 2835,  with ≥ 3 risk factors for diabetes were eligible for the HbA1c and RBG testing. RBG showed significant correlation with HbA1c . The regression equation was: y(HbA1c)=0.013*RBG+4.012. Using the ROC analysis, the cut-off value for RBG corresponding to an HbA1c of 5.7% (39 mmol/mol) (n=1121) was 113.5 mg/dl (6.3 mmol/L) .The AUC was 0.662 ± SE 0.10 (95% CI 0.642-0.682), .Cut-off value for RBG was 113.5 mg/dl (6.3 mmol/L) . AUC = 0.662 ± SE 0.10 (95% CI 0.642-0.682). ROC: Receiver Operating Characteristic Curve; RBG: Random Blood Glucose; AUC: Area Under the Curve.Cut-off value for RBG was 140.5 mg/dl (7.8 mmol/L) . AUC = 0.823 ± SE 0.16 (95% CI 0.792-0.854). ROC: Receiver Operating Characteristic Curve; RBG: Random Blood Glucose; AUC: Area Under the Curve.In this analysis, we intended to study the utility of RBG as a preliminary screening tool to identify persons at risk of developing diabetes and requiring further confirmatory diagnostic testing. The use of HbA1c test definitely has several advantages over that of blood glucose; but the higher cost of the test may limit its utility in large epidemiological studies. It may also be impractical in places where reliable test methods of HbA1c are not available. Therefore, the feasibility of using RBG in place of HbA1c or even a timed glucose measurement such as FPG or 2h PG values may be more advantageous and practical. In order to overcome this limitation, we assessed the cut-off values for RBG corresponding to the HbA1c values of 5.7% (39 mmol/mol) and 6.5% (48 mmol/mol) using ROC procedures. RBG values of 113.5 mg/dl (6.3 mmol/L) and 140.5 mg/dl (7.8 mmol/L) respectively were derived for prediabetes and diabetes defined by the above HbA1c values. However, it was noted that a RBG cut-off value of 113.5 mg/dl (6.3 mmol/L) did not show an acceptable level of sensitivity and specificity, and hence cannot be used to define prediabetes.An earlier study conducted in the US, tested the performance of four screening methods for diabetes and dysglycemia based on risk score, capillary blood glucose measurement and a combination of both . The stuBased on a comparison of RBG and corresponding oral glucose values, in a large number of randomly chosen individuals without a history of diabetes, it was suggested for Asian Indians with a RBG of >110 mg/dl (6.1 mmol/L) at screening can be recommended for definitive testing . This reOur cut-off value for diabetes 140.5 mg/dl (7.8 mmol/L) does agree with the reported observations from the various studies discussed here. However, the derived cut-off value of 113.5 mg/dl (6.3 mmol/L) did not have acceptable sensitivity and specificity to identify prediabetes.The use of RBG testing with convenience of sampling at any time during the day could substantially reduce time and cost of screening both at a community level and in a clinical setting. However, the limitation lies in the accuracy of the glucose monitors used and other factors such as postprandial time and age that may influence the performance of the RBG test as reported by Rolka et al. . It is aWe report than an RBG value of ≥ 140 mg/dl (7.8 mmol/L) could be used to identify people who should be subjected to confirmatory OGTT to diagnose diabetes. RBG measurement may be applied if HbA1c or timed glucose testing are not practical for large scale screening of undiagnosed diabetes.


Anaerobic digestion of food waste (FW) is typically limited to large reactors due to high hydraulic retention times (HRTs). Technologies such as anaerobic membrane reactors (AnMBRs) can perform anaerobic digestion at lower HRTs while maintaining high chemical oxygen demand (COD) removal efficiencies. This study evaluated the effect of HRT and organic loading rate (OLR) on the stability and performance of a side-stream AnMBR in treating diluted fresh food waste (FW). The reactor was fed with synthetic FW at an influent concentration of 8.24 (± 0.12) g COD/L. The OLR was increased by reducing the HRT from 20 to 1 d. The AnMBR obtained an overall removal efficiency of >97 and >98% of the influent COD and total suspended solids (TSS), respectively, throughout the course of operation. The biological process was able to convert 76% of the influent COD into biogas with 70% methane content, while the cake layer formed on the membrane gave an additional COD removal of 7%. Total ammoniacal nitrogen (TAN) and total nitrogen (TN) concentrations were found to be higher in the bioreactor than in the influent, and average overall removal efficiencies of 17.3 (± 5) and 61.5 (± 3)% of TAN and TN, respectively, were observed with respect to the bioreactor concentrations after 2 weeks. Total phosphorus (TP) had an average removal efficiency of 40.39 (± 5)% with respect to the influent. Membrane fouling was observed when the HRT was decreased from 7 to 5 d and was alleviated through backwashing. This study suggests that the side-stream AnMBR can be used to successfully reduce the typical HRT of wet anaerobic food waste (solids content 7%) digesters from 20 days to 1 day, while maintaining a high COD removal efficiency and biogas production. Anaerobic digestion (AD) is one of the most important and sustainable processes used for the treatment of organic solid waste (OSW). It combines pollution reduction, energy production, and nutrient recovery from OSW with limited environmental impacts  an ability to deal with higher organic loads even at unfavorable conditions; (ii) increased production of biogas with a higher methane content; (iii) less production of sludge; (iv) better quality effluent with no pathogens and solids; and (v) reduced footprint of the AD system . The study exhibited the feasibility of treating diluted FW at low HRT with a high COD removal efficiency and biogas production yield.3) was added to the influent to provide necessary  alkalinity. The sludge and the influent were sieved through a no. 20 mesh (0.841 mm) to remove particles that could clog the membrane tubes.The seed sludge  was obtained from the Howard F. wastewater treatment plant  and used for both batch and AnMBR experiments. The synthetic FW was prepared mimicking a typical post-consumer FW according to Ariunbaatar et al. . Ingredi3/L) was added to each bottle. Prior to incubation at mesophilic temperatures (35 ± 2°C), the serum bottles were flushed with helium gas to provide anaerobic conditions. The BMP test was continued until the cumulative biomethane production reached a plateau (after ~20–25 days of incubation) and the daily biogas production was measured by the volumetric liquid displacement method using sodium hydroxide (120 g NaOH/L) to capture carbon dioxide.Biomethane potential (BMP) tests were conducted to estimate the highest amount of biomethane that can be produced from the FW. BMP tests were carried out in serum bottles  in duplicates without mixing  of 0.1 m/s. The concentrate (rich in biomass) from the membrane modules was recycled back to the bioreactor. Membrane performance was monitored following Prieto et al. . When stable operation was achieved (as indicated by a constant volatile organic acid (VOA)/ partial alkalinity (PA) ratio, high COD removal efficiency (98%), and stable methane production), the HRT was reduced. After each step decrease in HRT, the bioreactor was allowed to reach stable operation before further lowering the HRT. HRTs of 10, 7, 5, 3, and 1 d corresponded to OLR values of 0.6, 0.86, 1.2, 2, and 6 gVS/L.d, respectively. The HRT and OLR were calculated based on the produced permeate volume from both membrane modules together.Membrane flux was monitored throughout the experiment. The HRT was varied by increasing the duration of the membrane filtration cycles to increase the system throughput at higher HRTs. The filtration time required for a specific HRT was divided into 4 cycles throughout the day, with relaxation periods occurring between active filtration cycles. Four cycles were applied during all HRTs, with an exception for an HRT of 1 d where the filtration cycle was increased to 8 per day. The filtration cycle intervals were controlled by a timer connected to the permeate pump. Starting from an HRT of 5 d, backwashing was performed after each filtration cycle to reduce the membrane fouling. The backwash flux was 10 times higher than the filtration flux and the backwash cycle was controlled by a timer.tot, CODsol), total nitrogen (TN), total phosphorus (TP), and total ammoniacal nitrogen (TAN) were analyzed with HACH test kits following the manufacturer's instructions . Total alkalinity (TA) and partial alkalinity (PA) were calculated based on the volume of the consumed hydrochloric acid (0.1N) by titrating with it until pH 5.75 and 4.3, respectively  from the bioreactor were collected approximately once in 2–3 days to prevent washout of bacterial biomass. Tedlar gas bags (1L) were used for sampling the biogas. Total solids (TS), total suspended solids (TSS), and volatile solids (VS) were determined following the standard methods , total nitrogen (TN), and total phosphorus (TP) of the seed sludge were 7.7 (± 0.1), 18.7 (± 2.4) mg/L, 13.1 (± 0.1) mg/L, 4,389.7 (± 10.7) mg/L, 3,886.0 (± 11.6) mg/L, 396.7 (± 2.4) mg/L, 405.0 (± 18.7) mg/L, and 103.8 (± 7.0) mg/L, respectively. The TS of the synthetic FW was always in the range of 238.6–266.6 mg/kg, and >95% were volatile solids.2) partial pressure in the headspace, with the effluent having a lower CO2 concentration, yielding a higher pH value. This explanation is supported by the lower effluent VOA concentrations , the ratio increased immediately but stabilized after a while . A similThe nutrient concentrations  in the influent (feed), bioreactor, and effluent are presented in The TAN concentration in the bioreactor and the effluent were 210.75 (± 31.4) and 162.63 (± 30.7) mg/L, respectively, during days 1–50. Starting on day 51 until the end of the experiment, they lowered to 138.28 (± 15) and 122.80 (± 20.4) mg/L, respectively . The higThe TP concentration in the bioreactor showed fluctuations with its concentration decreasing in the bioreactor over the course of operation . The TP tot and CODsol concentrations were 8.24 (± 0.12) and 3.31 (± 0.05) g/L, while the COD concentration in the bioreactor varied depending on the OLR (sol in the bioreactor increased yielding a higher COD concentration in the effluent (0.35–0.77 g COD/L) (sol was reduced immediately after 2 days resulting in an effluent COD concentration of 0.03–0.15 g/L. The highest CODsol concentration of 3.45 (± 0.13) g COD/L in the AnMBR mixed liquor was observed on day 61 after the loss of biomass (~3 L) and an over-feeding event. Nevertheless, the ultrafiltration membranes of the AnMBR were able to retain the remaining biomass in the system and recover its performance within a week. The first two over-feeding events resulted in an OLR shock, from which the AnMBR recovered quickly. Even during the unintentional over-feeding events on days 76 and 93, the AnMBR was able to recover in <2 days.The influent COD the OLR . When thg COD/L) . Howevertot and CODsol removal efficiencies were >97 and >95%, respectively. During the stepwise HRT decrement, the COD removal efficiency dropped by 3–5% and recovered after 2–3 days. The COD removal efficiency was not calculated during over-feeding events, i.e., operational days 57–60, 63–69, 76–79. During stable operation, >98% TSS removal efficiency was achieved. A similar decreased TSS removal efficiency was observed each time when the HRT was reduced . Due to several over-flowing and headspace leaking events the data from the wet tip meter was unreliable and the produced biogas volume could not be quantified during the initial operational days . Therefore, the value obtained from the BMP test was used to calculate the biogas production from the AnMBR. 4 / g COD , was achieved at an HRT of 3 days, although methane yields at 5 d and 1 d HRTs were very close to this value as well, measured as 0.124 and 0.125 L CH4/g COD, respectively (The BMP test of FW lasted for 25 days and reached a maximum of 472.15 (± 1.75) mL CHectively .3 of food waste treated was achieved at 5 d HRT at 48.9 MJ/m3 treated, whereas the energy content of biogas at 1 d and 3 d HRTs were 31.4 and 42.9 MJ/m3 treated, respectively . The COD balance for different HRTs is shown in This study showed that the AnMBR could treat diluted FW (7% solids content) and produce biogas with a high methane content at an HRT of 1 d. The OLR is a key parameter for biogas production through AD as process failures can occur at high organic loading rates (OLRs)  in a combined heat and power system can be sold to the grid for revenue, to offset the capital and operating costs of the system. In the European Union, the average cost of non-household electrical energy for EU-27 countries is 0.1173 EUR  concentrations in the bioreactor were higher than the influent throughout the course of operation . The TN 50 of TAN is around 3,800 mg/L  or dipotassium ammonium phosphate (K2NH4PO4), which contribute to the phosphorus removal . A typical HRT of 20 d was successfully reduced to 1 d in 100 d. The biological part of the system was fully stabilized after more than 2 weeks, and it was able to convert 50–76% of the influent COD into biogas with up to 70% methane content. Additional COD removal was performed by the membrane filtration process, making the COD removal efficiency of the whole system > 97%. Moreover, > 8% of the influent total suspended solids (TSS) was removed. The TN and TP removal efficiencies were estimated to be around 16.5 (± 3) and 40.39 (± 5)%, respectively. Furthermore, the energy output through biogas production indicates the economic feasibility of the side-stream AnMBR concept in treatment of diluted FW at low HRTs.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.JA, RB, and OO designed and conducted the experiments, analyzed the results, and drafted the manuscript. HR analyzed the results and drafted the manuscript. GE, PL, and DY supervised the work and gave inputs during the development of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


These results show that OD is very prevalent among patients with dementia and is associated with impaired functionality, malnutrition, respiratory infections, and increased mortality. New nutritional strategies should be developed to increase the compliance and therapeutic effects for this growing population of dysphagic patients.The prevalence of older patients with dementia and oropharyngeal dysphagia (OD) is rising and management is poor. Our aim was to assess the prevalence, risk factors, and long-term nutritional and respiratory complications during follow-up of OD in older demented patients. We designed a prospective longitudinal quasi-experimental study with 255 patients with dementia. OD was assessed with the Volume-Viscosity Swallowing Test and a geriatric evaluation was performed. OD patients received compensatory treatments based on fluid viscosity and texture modified foods and oral hygiene, and were followed up for 18 months after discharge. Mean age was 83.5 ± 8.0 years and Alzheimer’s disease was the main cause of dementia (52.9%). The prevalence of OD was 85.9%. Up to 82.7% patients with OD required fluid thickening and 93.6% texture modification, with poor compliance. OD patients were older ( Oropharyngeal dysphagia (OD) is a serious condition among patients with dementia with a prevalence of 32%–45% when clinically assessed and 84%–93% when instrumentally assessed . DementiThe screening of OD and its management in patients with dementia should be mandatory in psychogeriatric units (PU) of hospitals and healthcare centers, as OD is associated with negative clinical outcomes and impaired quality of life in these patients . The VolThe aim of this study was to assess, at 18 months follow-up, the prevalence, risk factors, and complications of OD in patients with dementia from a PU of an intermediate care hospital. We designed a prospective, longitudinal, quasi-experimental study on patients with dementia consecutively admitted to the PU of an intermediate care hospital  with 18 months follow-up to describe the prevalence of OD and the complications during the admission and follow-up period. On discharge, families and caregivers were given recommendations and advice on fluid adaptation according to the results of the V-VST, a clinical assessment tool that uses three volumes and viscosities in a progression of increased difficulty to assess signs of impaired safety and efficacy of swallow, texture-modified foods using one of two different textures (blended and easy mastication), nutritional supplements for malnourished patients or those at risk of malnutrition according to the Mini Nutritional Assessment short form (MNA-sf) , and oraWe studied 255 patients with dementia that were prospectively and consecutively recruited from the PU of Hospital de St. Jaume i Sta. Magdalena, Mataró, Catalonia, Spain between June 2013 and July 2016. Inclusion criteria were: patients over 18 years old and patients with dementia discharged from the PU who signed the informed consent. Exclusion criteria were: death during hospital admission, enteral nutrition, and refusal to participate. All participants and/or proxy decision makers were informed about the study and signed the informed consent. The study protocol was approved by the Ethics Committee of the Hospital de Mataró (CEIC 7/13) and was conducted according to the principles and rules laid down in the Declaration of Helsinki and its subsequent amendments and the EU rules for clinical trials on humans ).All participants were clinically assessed for OD with the V-VST during admission. The V-VST is a validated clinical assessment tool that uses three volumes  and viscosities  together with a pulse-oximeter (to detect silent aspirations) to evaluate clinical signs of impaired efficacy and safety of swallow ,16. DiagWe collected data on functional capacity with the Barthel Index that classifies the patients from 0  to 100  points according to their capacity or inability to perform the activities of daily living (ADL) ; comorbiDuring initial admission procedures (24–48h), trained nurses from the PU performed the V-VST and adapted: (1) fluids (volume and viscosity) to provide a safe and effective swallow; (2) solids (texture-modified food) according to swallowing and feeding evaluation by a dietitian using two different textures–blended diet and easy mastication; and (3) oral hygiene with an individualized protocol that included toothbrushing 3 times/day and antiseptic mouthwashes 2 times/day (chlorhexidine 0.12%) to reduce the oral bacterial load and the risk of respiratory infections . When patients had dentures, they were removed and placed in a disinfectant solution overnight; they also performed antiseptic mouthwashes twice a day (chlorhexidine 0.12%).Fluid viscosity was adapted into three different levels according to the results obtained from the V-VST: thin liquids for patients without risk of aspiration , in a range < 50 mPa·s, nectar viscosity and pudding viscosity. These lasts two levels were obtained using a thickener to increase their viscosity.-1. Likewise, pudding viscosity was prepared by adding 9 g of thickener to 100 mL mineral water and achieved a viscosity of 4539.5 mPa·s ± 530.93 (4500 mPa·s). This specific thickening agent was affected by salivary amylase and both levels of viscosity were below 50 mPa·s (thin liquid) when analyzed after an oral incubation of 30 seconds.Nectar viscosity was obtained by adding 4.5 g of thickener  to 100mL mineral water to obtain a shear viscosity of 98.61 mPa·s ± 3.78 (100 mPa·s) at a shear rate of 50 sTwo different textures, blended and easy mastication, were used. Blended diet was defined as a smooth and uniform consistency . Easy mastication diet consisted of soft dishes or moist food which can be broken into pieces easily . Modified texture diets were composed in 2 weekly menus: 2 for blended diet and 2 for easy mastication diet. Regarding the nutritional content, all the prescribed diets were normocaloric and normoproteic, corresponding to the following ranges: 1700–1800 kcal/day and 60–70 g of protein/day. Diets were supplemented, if needed. In order to increase the caloric content by 150 kcal per day, three high-caloric foods were given, such as oil and honey. In contrast, if the protein content needed to be increased, three high protein foods were selected to add between 16–18 g of protein per day such as fish or eggs. Nutritional supplements were prescribed according to accepted clinical practice at this institution .Families and caregivers were given personalized recommendations on discharge based on the treatment provided during admission. Recommendations consisted of four blocks of information: (1) adaptation of fluids (volume and viscosity); (2) texture adaptation (texture-modified foods) as previously described ; (3) nutritional supplementation with natural additives in patients at risk of malnutrition or malnourished (MNA-sf); and (4) oral hygiene recommendations according to the results of the OHI-S, including toothbrushing and the use of chlorhexidine mouthwashes). During admission, nurses carried out intense health education at the bedside for family members and caregivers on these main topics. Follow-up visits were performed by telephone interviews with families and caregivers and review of the clinical outcomes and complications registered in the electronic medical history  at 3, 6, and 18 months after discharge. Individual clinical history allows access to all the medical information of a patient and can be consulted from any health center in Catalonia under security and confidentiality protocols. Compliance with the recommendations was checked with a specially designed questionnaire. The outcomes associated with OD like functional status, LTRI, hospital readmissions and survival were registered. p value, the magnitude of the observed effect, and their clinical and biological plausibility. Statistical significance was accepted if p values were less than 0.05.Qualitative data were presented as relative and absolute frequencies and analyzed by the Fisher’s exact test or the Chi-square test. Continuous data were presented as mean ± standard deviation (SD) and compared with the T-test (intergroup comparisons) or Paired T-test (intragroup comparisons); for those variables that did not follow a normal distribution, we used the nonparametric Mann–Whitney U-test (intergroup comparisons) or the Wilcoxon-paired test (intragroup comparisons). The cumulative incidence of respiratory infections was calculated taking into account the total patients who suffered respiratory infections (LTRI and pneumonia) over 18 months/total number of patients. To analyze the adjusted effect of OD on complications, we used a Multivariate Cox Regression for mortality and Multivariate Logistic Regression for respiratory infections including LRTI and pneumonia. In these models, OD was adjusted for age, sex, functional capacity (Barthel index), nutritional status (MNA-sf), and cognitive deterioration (GDS). Results were interpreted according to the obtained Two hundred and fifty-five older patients with dementia were recruited (61.6% women) with a mean age of 83.5 ± 8 years. The main cause of dementia in the study population was Alzheimer’s disease (52.9% (135)), followed by mixed dementia (25.1% (64)), Lewy’s bodies dementia (5.5% (14)), mild cognitive impairment (5.1% (13)), vascular dementia (3.1% (8)), Parkinson’s disease associated dementia (1.6% (4)), and other causes (6.7% (17)). Up to 60% (153) of study patients presented a GDS ≥ 6 (severe dementia). A Mini Mental State Examination (MMSE) showed that the majority of patients were in a moderate–severe cognitive impairment (87.4%). Mean Charlson score was 2.01 ± 1.4 points and Barthel Index was very low, 30.8 ± 24.7on admission and 39.6 ± 26.5 on hospital discharge. Up to 47.8% (122) of patients were admitted to the Psychogeriatric Unit of the hospital, 44.7% (114) from home and 7.5% (19) from nursing homes. p = 0.007), with poorer functional capacity on admission  and greater severity of dementia (< 0.0001) than non-dysphagic subjects (ND) (Up to 85.9% (219) patients with dementia presented signs of OD according to the V-VST. Signs of impaired efficacy vs. safety of swallow were found in 83.1% (182) and 81.7% (179) of patients, respectively, and 64.8% (142) presented both impairments. Patients with OD were older  . We founp < 0.0001 vs. nectar and pudding). The safest viscosity was pudding (89.0%), presenting significant differences when compared with liquid for all volumes (p < 0.0001 for 5 and 20 mL and p < 0.01 for 10 mL). We also found significant differences when comparing nectar vs. liquid at 5 mL volume (p < 0.0001). No relationship was observed between volume and impaired safety signs (p < 0.05) and pudding vs. liquid    .Following the V-VST results, only 17.3% (38) of patients could safely drink thin liquid (<50 mPa·s), 55.2% (121) needednectar (100 mPa·s) and 27.5% (60) pudding viscosity (4500 mPa·s) to achieve a safe swallow. Regarding texture modified diets, 53.4% (117) of patients needed easy mastication diet, 40.2% (88) blended diet, 5.9% (13) mixed diet (combining both diets), and only 0.5% (1) could take a normal diet without a texture adaptation. Up to 31% (79) of patients were totally feeding dependent. 2. According to MNA, 51.6% (127) of study patients were malnourished, 44.7% (110) were at risk of malnutrition, and only 3.7% (9) presented a normal nutritional status. Mean MNA-sf in patients with OD was significantly lower than ND , however, there were no differences in categorized nutritional status between both groups (Mean weight on admission was 62.6 ± 12.2 kg and the BMI was 26.7±1.2 kg/mh groups . p < 0.0001) due to a significant debris score reduction  as the calculus index did not improve. There were no main differences in oral health and hygiene status between OD and ND patients on admission and discharge.According to OHI-S, patients showed fair mean oral health score (2.7 ± 1.2), with a debris index of 1.4 ± 0.8 and calculus index of 1.3 ± 1.0. Regarding OHI-S categorization, 27.6% (24), 56.3% (49), and only 16.1% (14) of patients presented a poor, fair, and good OHI-S, respectively. Of the study participants, 40.1% (65) had less than 10 teeth and 31.4% (59) used dentures. On discharge, after nursing oral health intervention, the OHI-S significantly improved  and those who had a higher non-significant prescription of psychoactive drugs . The incidence of LTRI during admission was similar in both groups , although there was a trend toward a higher rate of other general complications in the OD group , urinary infection being the most common affect over the whole study population (16.5% (42)). On discharge, 54.1% (138) of patients went home  and 38% (97) to a nursing home . The average stay in PU was 54.8 ± 68.4 days . The most common pathologies found in the study population were arterial hypertension (66.7%), diabetes mellitus (27.5%), atrial fibrillation (18.4%), and stroke (12.2%). The most frequent reason for admission was the psychological and behavioral symptoms associated to dementia (57.5%). During admission, these symptoms were slightly more frequent in ND patients  and reported difficulties in preparing the recommended diet textures (p = 0.055) and high viscosity of fluids (p < 0.0001). During the follow-up period, up to 11.7% of OD patients did not follow the recommendations about texture diet adaptation and up to 40.6% did not follow fluid adaptation recommendations due to the caregiver’s difficulty to adapt textures and viscosities . The most frequent reason for not following recommendations was the patient’s rejection of high viscosity and/or textures. The main factors that influenced compliance during follow-up were the presence of non-compliance during admission (The main complications of patients with OD during follow-up were LTRI and pneumonia that was diagnosed in 43.0% (99) and 12.6% (28) of patients, respectively. Up to 21.2% (49) were readmitted with respiratory infections. Finally, 72 patients died (10.5% (23) at 3 months, 8.2% (16) at 6 months, and 18.3% (33) at 18 months). p = 0.040)) as well as its prevalence ). We observed significant differences between both groups for LTRI  but not for pneumonia . In this period, episodes of hospital readmissions were more frequent in ND patients (p = 0.015), however, this difference was not significant for respiratory infections (p = 0.828) or for readmissions for other diseases (p = 0.075) (p = 0.0002) (p = 0.056) as well as respiratory infections . In addition, age was independently associated with mortality and respiratory infection during the follow-up period (OR-1.04 (95%CI 1.012–1.075); p = 0.012 and OR-1.05 (95%CI 1.004–1.088); p = 0.029) and functionality was independently associated with mortality (OR-0.98 (95%CI 1.012–1.075); p = 0.012)  during the study period was higher in OD patients  . During  0.0002) . After m= 0.012) .This study clearly shows that patients with dementia admitted to the PU of an intermediate care hospital had a very high prevalence of OD (85.9%), malnutrition (MN) (51.6%), and poor or fair oral health status (83.9%). Risk factors for OD were older age, functional dependence, and severity of dementia according to GDS/FAST. In these patients, OD was associated with a greater risk of being malnourished than those without OD on admission, and with respiratory infections and mortality during the 18-month follow-up. Patients with OD and dementia required high viscosity fluids and texture-modified diets to provide a safe swallow but compliance with these treatments was very poor as well as their clinical outcomes. These results might suggest that the therapeutic effect of this strategy is weak and therefore the nutritional management of OD patients with dementia must be improved, but they also suggest that OD management in severely demented patients must be close to palliative care as we cannot change the severity and natural history of OD in these patients.We included very old OD patients with dementia in this study. Previous studies have also reported similar age ranges as the age of these institutionalized patients with dementia is generally very advanced ,23,24. Rp < 0.0001). In addition, it should be taken into account the advanced stage of dementia of the patients in the present study and their severe cognitive deterioration. All this data shows the high level of impairment of our study patients which could explain the severe complications and poor prognosis they had despite following a similar management strategy for OD. Taken all together, we believe that this specific kind of phenotype of advanced demented patients probably needs a palliative treatment rather than a compensatory one. The phenotype of patients and the natural history of their condition is the main variable that should drive the selection of active, compensatory, or palliative treatments for their swallow dysfunction.There is a higher incidence of aspiration in patients with more severe dementia . Our preAs we have described previously, in this study, we observed an increase in safe swallow when viscosity increased. Impairments in safety of swallow increased only with the highest volume assessed except for pudding viscosity. In contrast, impaired efficacy was more prevalent with increased volume ,34. The The third point of our intervention was oral health and hygiene (OH). Patients with dementia, especially in advanced phases, often have poor oral health and OH and missing teeth ,45. Ortep = 0.040). Similar results for LTRI, in this case by annual incidence rate, were described among older OD patients living in the community  [p = 0.002) and, after multivariate analysis, OD was also closely associated with mortality (OR-2.8) and respiratory infections (OR-2.4). In PU patients, studies have shown that mortality is associated with dysphagia [Finally, the main complication during the study in our OD patients was respiratory infections, with significantly higher cumulative incidence at 18 months compared with ND patients  . Howeverysphagia ,27,36, fysphagia  and thusOD is a prevalent condition in patients with advanced dementia and is associated with severe complications, poor prognosis, and low compliance with fluid and texture adaptation. Taking into account these findings, we propose a management plan for these patients according to the severity of dementia. For the early–moderate stages, we suggest using a multimodal treatment with a periodic on-site thorough monitoring based on the MMI with better thickening agents, texture modified diets, natural supplements, and nutritional products with high palatability to improve adherence and patients’ prognosis. In the more severe stages of dementia, with worst functionality and high rates of complications including mortality, a palliative MMI management with a less exhaustive follow-up is proposed to reduce the rate of complications related to OD. Supported by the study results, we consider that new nutritional strategies should be developed to increase patient compliance and its therapeutic effects in the clinical management of OD patients with dementia and that new evidence regarding these promising interventions should be provided.


The incidence of hepatocellular carcinoma (HCC) has consistently increased over the last two decades. Although surgical resection is the preferred treatment for HCC, approximately 80% of the patients are not suited for surgery because the tumors are in advanced stage of the disease and unresectable. Locoregional therapies like anti-vascular ultrasound (AVUS) provide a unique alternative for treatment. In this study we evaluate the use of repeated subsequent AVUS therapy as an approach to optimize the therapeutic efficacy by targeting tumor vasculature at different times. This approach can overcome the heterogeneity in tumor vasculature structure and functionality often observed at time of therapy. For this purpose, we evaluated two regiments of subsequent AVUS treatments with a predetermined time interval between the treatments. The results showed that AVUS when applied subsequently in a shorter duration, boosts the therapy effects showing more than 75% reduction in tumor perfusion post therapy. However, this improvement was lost for a longer duration between subsequent therapies. These findings demonstrate the significance of the viability of tumors for maximizing the therapeutic effects of tumor vasculature targeting therapies.p < 0.001. The 7DST group showed a reduction in tumor perfusion of 45.3%, which was significant compared to the 2DST group (p < 0.001) but not different from the ST group (p = 0.2). The use of subsequent targeted AVUS therapies applied shortly (two days) after the first treatment enhanced the anti-vascular effect of ultrasound. This gain, however, was lost for a longer interval (1 week) between the therapies, possibly due to tumor necrosis and loss of tumor viability. These findings suggest that complex interplay between neovascularization and tumor viability plays a critical role in treatment and, therefore, must be actively monitored following treatment by CEUS for optimizing sequential treatment.The response of hepatocellular carcinoma (HCC) to anti-vascular ultrasound therapy (AVUS) can be affected by the inherent differences in tumor vascular structure, and the functionality of tumor vessels at the time of treatment. In this study, we evaluate the hypothesis that repeated subsequent AVUS therapies are a possible approach to overcome these factors and improve the therapeutic efficacy of AVUS. HCC was induced in 30 Wistar rats by oral ingestion of diethylnitrosamine (DEN) for 12 weeks. A total of 24 rats received treatment with low intensity, 2.8 MHz ultrasound with an intravenous injection of microbubbles. Treated rats were divided into three groups: single therapy group (ST), 2-days subsequent therapy group (2DST), and 7-days subsequent therapy group (7DST). A sham control group did not receive ultrasound therapy. Tumor perfusion was measured by quantitative contrast-enhanced ultrasound (CEUS) nonlinear and power-Doppler imaging. Tumors were harvested for histologic evaluation of ultrasound-induced vascular changes. ANOVA was used to compare the percent change of perfusion parameters between the four treatment arms. HCC tumors treated with 2DST showed the largest reduction in tumor perfusion, with 75.3% reduction on average for all perfusion parameters. The ST group showed an average decrease in perfusion of 54.3%. The difference between the two groups was significant  Hepatocellular carcinoma (HCC) is the most common primary liver cancer, ranking 6th in incidence among other cancers worldwide . AccordiCurrently, HCC management is multidisciplinary and depends on tumor stage and liver function at the time of diagnosis and treatment. The standard of care is early resection and orthotopic liver transplant for those patients who are eligible for surgery ,6,7. ImaIn our earlier studies, we introduced the use of antivascular ultrasound (AVUS) as a potential noninvasive locoregional therapy targeting the tumor vasculature ,11,12,13One difficulty generally experienced with tumor vasculature targeting therapies is that susceptible tumor vasculature must be present and functional for the therapy to be effective ,17,18. TThe aim of this study is to evaluate the use of subsequent repeated treatments as a means of optimizing AVUS therapeutic effects. These effects are assessed using contrast-enhanced-ultrasound imaging (CEUS) in a diethylnitrosamine (DEN) induced orthotopic HCC model in rats, which is known to closely emulate the progression and growth of human HCC ,23.−1 oxygen, and a tail vein 26 G catheter  was inserted. The animal was positioned supine on a heated bed, the abdomen was depilated, and continuous vital signs including body temperature, heart rate, and respiratory rate were recorded. At the completion of the study, the rat was euthanized by carbon dioxide asphyxiation, and necropsy was performed.All animal protocols were approved by the university institutional animal care and use committee. Thirty Wistar male rats  weighing between 300 and 400 g, with an average of 6 months of age, were acquired and kept under controlled environmental conditions (25 °C and a 12 h light/dark cycle). After one week of acclimation, the rats were initiated on 0.01% diethylnitrosamine  in their drinking water, which they ingested ad libitum for 12 weeks. Ultrasound imaging and therapy were performed under anesthesia. The rat was placed in a non-rebreathing gaseous anesthetic system  and general anesthesia was induced with 4% isoflurane . A nose cone was taped in place, anesthesia was maintained with 1% to 3% isoflurane and 1.5 to 2.0 L.minThe rats were monitored for the development of tumors using grayscale ultrasound  beginning 11 weeks into the DEN diet and weekly thereafter. During monitoring sessions, diagnostic scans were performed, identifying and measuring visualized lesions. A single tumor most suitable for AVUS therapy was selected from the often-multiple tumors developed in the liver based on the tumor location , size (6 to 14 mm diameter), hyperenhancement with microbubble administration, and minimal cystic or hemorrhagic changes as identified in the ultrasound images. After selecting and clearly identifying the tumor, the diagnostic transducer was secured in an adjustable mount to maintain a fixed position over the tumor. 2 (corresponding to pressure amplitude of 0.23 MPa) and duty cycle of 100 percent, for a total of 6 min with 2 min on and off cycles. Then, 0.5 mL perflutren microbubbles  were injected as a bolus via the tail vein catheter prior to the first insonation and 0.2 mL prior to the second 2 min insonation cycle; fractionating the microbubble administration ensured that microbubbles remained in circulation throughout the therapy.A low-intensity, continuous non-focused sinusoidal plane wave ultrasound therapy was performed at 2.8 MHz using 15 mm single element plane disk transducer. During therapy, the diagnostic transducer was replaced with the therapeutic probe in the same location above the tumor to keep the alignment with the imaged HCC. Therapy dose was selected based on our previous studies ,11,12,13n = 10 rats), 2-days subsequent therapy group , and 7-days subsequent therapy group . The single therapy group received one therapy session on a single day. The rats from this group were sacrificed on the same day for histology assessment. The 2DST group received a second therapy two days after the first therapy. The 7DST received the second treatment session 7 days after the first treatment. Two cases, one from the ST group and one from 7DST, did not respond to therapy due to technical difficulties in contrast injection and were not included in the analysis. The rats from subsequent therapy groups were sacrificed following the second treatment and the treated tumors were harvested for histologic analysis. A control group (n = 6) received a sham therapy in which the microbubbles were replaced with 0.7 mL normal saline, and the ultrasound therapy transducer was not switched on. The animals were sacrificed following sham treatment and the tumors were harvested for histologic analysis.The rats received ultrasound anti-vascular treatment from the 12th to the 17th week from the start of the DEN diet. The animals in the treatment group were divided into three groups: single therapy group  imaging was performed to assess tumor perfusion before and after AVUS treatment using nonlinear contrast (NLC) and power Doppler (PD) modes. This involved continuous serial imaging at 10 fps during the contrast enhancement of the tumor. Imaging presets and time compensation gain were optimized and kept fixed for pre- and post-therapy imaging. An intravenous bolus injection of 0.05 mL microbubbles was used for each imaging session.Nonlinear contrast (NLC) images were analyzed by using the scanner software. The border of the tumor was manually outlined to define a region of interest (ROI) in the time series of contrast-enhanced images. The mean intensity of the ROI was fitted to a bolus perfusion model , and theThe contrast-enhanced PD images were analyzed using an IDL (Interactive Data Language)-based platform described earlier ,23. ThisThe NLC and Doppler measurements were made on the whole tumor as well as regionally in the center and periphery of the tumor.t-tests on the decrease in tumor perfusion after therapy. p < 0.05 was considered significant. One-way analysis of variance (ANOVA) was used to compare the percent change of perfusion parameters between the four treatment arms. ANOVA was followed by Tukey’s test as a post hoc test. D’Agostino-Pearson test was used to check the normal distribution of the data. Statistical analysis was performed using MedCalc . The average (±standard error SE) of the quantitative data for the perfusion parameters  of the treatment groups was compared by one-tailed paired Student’s At the completion of each study, tumor samples were collected for histological examinations. Tumors were preserved in 10% phosphate-buffered formalin for 48–72 h before being transferred to 50% ethanol, embedded in paraffin, and processed for histological examination with hematoxylin and eosin (H&E) staining. The tumor slices were examined under microscope . Images were acquired and the percentage area of hemorrhage was recorded using ImageJ software . The acqAll animals developed liver disease and multiple foci of hepatocellular carcinoma (HCC), seen on B-mode ultrasound imaging . These tp = 0.06, with a 51.4% reduction in tumor perfusion. PI, on average, dropped from baseline 6.4 ± 2.3 to 2.9 ± 1.4, p = 0.05, with a percentage decrease of 57.0%. Similarly, power Doppler parameters showed a reduction in tumor perfusion after AVUS therapy, where VAR decreased from 63.1 ± 11.2 to 31.0 ± 11.4, p = 0.08, with a percentage decrease of 54.5%. FVPI decreased from 37.35 ± 5.99 to 17.67 ± 5.52, p = 0.03, representing a decrease of 58.3%.HCC tumors that received a single treatment showed a reduction in NLC derived perfusion parameters, where PE decreased from 6.2 ± 2.4 to 3.0 ± 1.6 post therapy, p = 0.02, after therapy, with a percentage decrease of 82.7%. Mean PI showed a similar significant decrease of 82.6%, from 6.0 ± 3.5 a.u. to 1.4 ± 0.6 a.u., p = 0.03. The HCC tumors that were treated subsequently within two days apart showed a remarkable reduction in tumor perfusion after therapy, where PE decreased from 5.4 ± 2.2 to 1.1 ± 0.4, p = 0.02, with a 65.5% decrease, and FVPI decreased from 31.37 ± 7.78 to 8.32 ± 1.39, 70.35, p = 0.004.Likewise, power Doppler parameters showed a significant reduction in perfusion kinetics after AVUS therapy, where VAR decreased from 59.8 ± 12.8 a.u. to 20.6 ± 8.5 a.u., p = 0.2, showing a 52.6% decrease in tumor vascularity. PI decreased from 2.9 ± 1.0 to 1.6 ± 1.1, p = 0.3, with a 47.2% decrease in tumor perfusion. Similarly, PD derived VAR decreased from 58.8 ± 8.8 to 33.7 ± 2.9, 49.6%, p = 0.006, and FVPI went down from 21.63 ± 4.66 to 14.72 ± 1.16, p = 0.07, with 32.0%. HCC tumor perfusion decreased after subsequent therapies applied within 1 week, where mean PE went down from a baseline of 3.4 ± 1.1 to 1.6 ± 1.3 post therapy, p < 0.001). The reduction in tumor perfusion was significantly larger in 2DST compared to 7DST, which shows a reduction in tumor perfusion of 45.3%, p < 0.001. The comparison of ST and 7DST did not show a significant difference between the two groups. On a case-by-case basis, the decrease in tumor perfusion was more uniform in the 2DST group, compared to the ST or 7DST groups , sham vs. 2DST and 7DST (p < 0.001), and ST vs. 2DST and 7DST (p < 0.001) were statistically significant. However, the difference between 2DST and 7DST was not significant (p = 0.2). Histological analysis of the H&E-stained HCC tumors demonstrated that percentage hemorrhagic areas significantly increased after subsequent AVUS therapies A. H&E-stIn the 2DST group, the vascularity of treated tumors returned to its baseline level two days following the first therapy, while the 7DST cases that were followed 7 days post first therapy did not show the same trend . In 2DSTp < 0.05) for both the groups. In both groups that received subsequent therapies, viz., 2DST and 7DST groups, it was observed that following the first treatment, the tumor vascularity decreased largely in the rim region. The vascularity decreased by 77.8% and 74.1% in the rim compared to 52.6% and 48.6% in the center of the 2DST and 7DST groups, respectively. The reduction in the vascularity of the two regions was significant  showed a substantially large reduction in tumor perfusion of more than 75% on average, which was significantly larger than that seen in tumors which received a single therapy, showing about 54% reduction only. Several factors could be responsible for the observed difference between the two groups. First, the use of subsequent treatments provides the opportunity of targeting new blood vessels formed by angiogenesis between the treatments. Second, the damages to the outer vessels in the first treatment allow an increased penetration of ultrasound beam to the center of the tumor in following treatments. Our results showed that the rim region of the tumor was highly affected by AVUS and demonstrated a larger reduction in tumor vascularity following the first treatment, compared to lesser effects observed in the center region. An additional explanation for the increased effectiveness of subsequent therapies is related to the activity of the microvasculature, which varies with time . EarlierThis study also investigated the effect of time interval between subsequent therapies on tumor response. The selection of the two time points for subsequent therapies at 2 and 7 days was based on our aim to compare the effects of subsequent AVUS therapies when given in a short interval and a longer interval. Stronger treatment effects were observed in the group that received subsequent therapies in two days, compared to a much lesser effect in the group that received the second treatment a week later. This was rather an expected finding as the immediate changes could be boosted with a second therapy in a short duration, while waiting for a longer duration till the effects of the first therapy have been diminished would have lesser effects. The stronger effects of a subsequent treatment within a shorter duration could be related to the tumor being more viable two days from therapy and in an earlier stage of tumor growth and ongoing angiogenesis. On the other hand, seven days later, changes related to tumor aging occur, including tumor necrosis, hemorrhage, calcification and loss of vascularity, making them less responsive to therapy. The histopathology analysis showed more necrosis in 7DST compared to 2DST, reflecting the tumor aging process.An interesting observation in the subsequent therapy tumor groups is that, following the first AVUS treatment, tumor perfusion increased to the baseline level over the first two days, while it did not show the same pattern when evaluated after a week. These findings also indicate the viability of tumors within two days from the first therapy, as angiogenesis and the formation of new vessels make them ideal for a second therapy. On the other hand, seven days later, the tumor ages and loses some of its vascularity, making it less responsive to a subsequent therapy.This study is not without limitations. An important concern is whether there are any unwanted effects with multiple treatments. AVUS therapy is ideally suited for recurring treatments due to the use of low energy ultrasound, which allows subsequent treatments. Although all the animals tolerated the multiple treatments well, a more detailed study investigating the side effects of such treatment is needed. The use of tumor vascular targeting therapies remains challenging and can be affected by the inherent differences in the structure and functionality of HCC tumor vasculature. To overcome these limitations, we evaluated two predetermined regiments of subsequent AVUS treatments with a fixed time interval between the treatments. The results showed that AVUS therapy effects were boosted when applied subsequently in a shorter duration. This improvement, however, was lost for a longer duration between subsequent therapies. These findings demonstrate the significance of the viability of tumors for targeting the tumor vasculature and maximizing the therapeutic effects. With improved imaging techniques such as contrast enhanced endoscopic ultrasound (CEU) , with it


The coronavirus disease 2019 pandemic has caused unprecedented disruptions to education in the United States, with a large proportion of schooling moving to online formats, which has the potential to exacerbate existing racial/ethnic and socioeconomic disparities in learning. The authors visualize access to online learning technologies using data from the Household Pulse Survey from the early fall 2020 school period (August 19 to October 26). The authors find that 10.1 percent of children participating in online learning nationally did not have adequate access to the Internet and a computer. Rates of inadequate access varied nearly 20-fold across the gradient of parental race/ethnicity and education, from 1.9 percent for children of Asian parents with graduate degrees to 35.5 percent among children of Black parents with less than a high school education. These findings indicate alarming gaps in potential learning among U.S. children. Renewed investments in equitable access to distance-learning resources will be necessary to prevent widening racial/ethnic and class learning disparities. We use data from the weekly Household Pulse Survey , a rapidLack of adequate access varied nearly 20-fold across the gradient of parental race/ethnicity and education, ranging from 1.9 percent (95 percent CI = 1.2 percent to 2.7 percent) for children of Asian parents with graduate degrees to 35.5 percent (95 percent CI = 24.1 percent to 47.0 percent) among children of Black parents with less than a high school education .These rates varied fourfold by race/ethnicity, ranging from 3.8 percent (95 percent CI = 2.8 percent to 4.9 percent) for Asian parents to 15.6 percent (95 percent CI = 13.5 percent to 17.7 percent) for Black parents, and fivefold by parental education, ranging from 3.9 percent (95 percent CI = 3.5 percent to 4.3 percent) for parents with graduate degrees to 20.3 percent (95 percent CI = 16.5 percent to 24.2 percent) for parents with less than high school education.Even before COVID-19, the United States had profound and persistent disparities in educational attainment and learning by race and social class . The resBy visualizing the gradient by parental race/ethnicity and education, we highlight that COVID-19 is likely potentiating the intergenerational propagation of gaps in educational outcomes and moreover in a differential manner by race/ethnicity. These findings therefore demonstrate that disparities in remote learning during COVID-19 must be examined in an intersectional fashion . StratifAs education is a key social determinant of health, and a driver of economic opportunities, the implications of these widening education gaps are myriad and may ripple out into disparities in numerous sectors of society . These tClick here for additional data file.Supplemental material, sj-docx-1-srd-10.1177_2378023121992607 for U.S. Children “Learning Online” during COVID-19 without the Internet or a Computer: Visualizing the Gradient by Race/Ethnicity and Parental Educational Attainment by Joseph Friedman, Hunter York, Ali H. Mokdad and Emmanuela Gakidou in Socius


A shortness of breath and light-headedness/headaches were also noted. Conclusions: In conclusion, wearing an FFP2 covered by a surgical mask induces a reduction in circulating O2 concentrations without clinical relevance, while an increase of heart frequency and a sensation of shortness of breath, light-headedness/headaches were recorded.Background: Safety in medical work requires eye protection, such as glasses, and protective facial masks (PFM) during clinical practice to prevent viral respiratory infections. The use of facial masks and other full personal protective equipment increases air flow resistance, facial skin temperature and physical discomfort. The aim of the present study was to measure surgeons’ oxygenation status and discomfort before and after their daily routine activities of oral interventions. Methods: 10 male voluntary dentists, specializing in oral surgery, and 10 male voluntary doctors in dentistry, participating in master’s courses in oral surgery in the Department of Oral Surgery of the University of Chieti, with mean age 29 ± 6 (27–35), were enrolled. This study was undertaken to investigate the effects of wearing a PFM on oxygenation status while the oral surgeons were actively working. Disposable sterile one-way surgical paper masks  and FFP2  were used and the mask position covering the nose did not vary during the procedures. The FFP2 was covered by a surgical mask during surgical treatment. A pulse oximeter was used to measure the blood oximetry saturation during the study. Results: In all 20 surgeons wearing FFP2 covered by surgical masks, a reduction in arterial O The aim of the present study was to measure the surgeons’ oxygenation status and discomfort before and after their daily routine activities of dental operations.The global impact of the novel SARS-CoV-2 has had severe implications for dental healthcare providers. The safety of medical work requires an adequate use of facial protective equipment against droplet transfer of SARS-CoV-2 . Eye pro flashes . It appeDuring the study period, May 2020 to October 2020, 10 male voluntary dentists, specializing in oral surgery, and 10 male voluntary doctors in dentistry, participating in a master program in oral surgery from our Department of Oral Surgery of the University of Chieti-Pescara, Italy with mean age 29 ± 6 (27–35), were enrolled. The study was carried out in observance of the Helsinki Declaration (revised version of Tokyo in 2004) and Good Clinical Practice Guidelines. All the surgeons signed informed consent for the adopted noninvasive procedure. The inclusion criteria were experience in oral surgery and the use of PFM. The primary exclusion criteria were presence of inflammation on the facial skin, lax skin, showing facial aging, allergic rhinitis and nasal septum deviations, facial treatment, including antiaging facial skin resurfacing, facial soft tissue augmentation or dermal filler, severe illness, facial skin disease, head and neck radiation therapy, chemotherapy, uncontrolled diabetes and beard. They had all previous experience in the use of a different type of PFM. In the previous hours, they had not experienced athletic training. The presence of respiratory diseases or smoking was exclusion criteria and none of the surgeons were overweight. After a thorough preliminary examination, the surgeons underwent pulse oximetry evaluation, being extensively informed concerning the study procedures. The surgeons entered a room with a constant temperature for 10 min to allow them to acclimatize. This research was undertaken to investigate the effects of wearing a PFM (FFP2) covered by surgical mask on oxygenation status while the oral surgeons were actively working. Disposable sterile one-way surgical paper masks  and FFP2  were used and the mask position did not vary during the procedures (covering the nose). The FFP2 was covered by a surgical mask during surgical treatment.n = 25);Duration of the operations was up to 20 min, (n = 20);Duration of the operation was between 20–40 min (n = 15);Duration of the operations was between 40–120 min (n = 4).Duration of the operations was between 120–240 min  scale. All sensations were scored by means of a 100 mm VAS from 0 (no discomfort) to 100 (worst discomfort imaginable). A pulse oximeter with a recyclable clip type finger probe  was used to measure the blood oximetry saturation during the study. The Surgeons were encouraged to behave in their usual manner throughout the oral surgery. The finger probe was applied to the second finger of the right hand. Just before the operation, pulse rate and oxygen saturation values were recorded. At the end of the oral surgery, the pulse oximeter was utilized again, and the values were recorded. During this study, no surgeon developed the COVID-19 disease.p < 0.05.The research sample size was measured through a dedicated clinical software able to calculate the quantity of subjects needed to achieve statistical significance for quantitative analyses of hypoxemia and discomfort. The statistical model was performed for dichotomous variables (yes/no effect) according to the following parameters: incidence effect (85% for the Test group and 10% for the control group), alpha = 0.05 and power = 95%. The optimal research sample size was 20 surgeons. The study data were statistically evaluated by the software package Graphpad 8.0 . The normal distribution of the study data was evaluated by the Kolmogorov–Smirnov test. The descriptive statistics of all study variables was provided by means and standard deviations (SD) of all the experiments. The comparison of the groups on the research variables were evaluated by the two-way ANOVA test followed by post hoc Tukey HSD test. The one-way ANOVA followed by Tukey post hoc test was performed to evaluate the significance of the comparison between the study groups of shortness of breath and light-headedness/headache VAS score perception. The level of significance was set at 2 saturation was recorded from around 97.5% before surgery to 94% after surgery (n = 25): an arterial O2 saturation was recorded from around 97.5% before surgery to 94% after surgery. Heart rate from 60 ± 9 bpm before surgery to 83 ± 12 bpm after surgery was also noted. Shortness of breath scored 30.33 ± 7.17 while light-headedness and headaches scored 21.33 ± 5.85.Duration of the operations was up to 20 min (n = 20): an arterial O2 saturation was recorded from around 97% before surgery to 94% after surgery. Heart rate from 61 ± 7 bpm before surgery to 85 ± 11 bpm after surgery was also noted. Shortness of breath scored 34.33 ± 6.91 while light-headedness and headaches scored 24.33 ± 5.11.Duration of the operations was in between 20–40 min (n = 15): an arterial O2 saturation was recorded from around 98% before surgery to 92% after surgery. Heart rate from 61 ± 8 bpm before surgery to 95 ± 10 bpm after surgery was also noted. Shortness of breath scored 35.33 ± 7.17 while light-headedness and headaches scored 28.33 ± 5.87.Duration of the operations was in between 40–120 min (n = 4): an arterial O2 saturation was recorded from around 97.5% before surgery to 91% after surgery. Heart rate from 60 ± 7 bpm before surgery to 98 ± 12 bpm after surgery was also noted. Shortness of breath scored 39.33 ± 7.64 while light-headedness and headaches scored 31.18 ± 4.85.Duration of the operations was in between 120–240 min . Wearing an PFM has a high impact on the cardiopulmonary resuscitation efficacity, in fact it increases rescuer’s fatigue and reduces chest compression with more stringent requirements on the depth and frequency, thus compromising the rescue maneuvers [2max by 13% related to an increased airway resistance [2 levels. In fact Anesthesiologists wearing a facial mask during percutaneous tracheostomy can experience dyspnea, tachycardia and tremor after 30 min [The present study results indicate that continuous wearing of Facial Masks during oral surgery led to a decrease in oxygen saturation of hemoglobin and an increase in heart rate. From the results, it looks like that the data show regular variation with the increase of operation time. Additionally, light-headedness and headaches and thermal discomfort were recorded. Normal blood Ortifacts . Pulse ortifacts . It is urtifacts ,27. The rtifacts . Reducedrtifacts . A face rtifacts . The usertifacts . Headachrtifacts . Protectrtifacts . Similarrtifacts  in most rtifacts , presencrtifacts , rash/irrtifacts  and discrtifacts . The usertifacts . The perrtifacts . A smallrtifacts . It was rtifacts  then incg a mask . It is ng a mask . Sympathg a mask ,40,41. Taneuvers . N95 proaneuvers . A recenaneuvers . In factsistance . There asistance ,46,47. Isistance ,49,50 wisistance ,51. The sistance , increasr 30 min . No surgr 30 min . In the 2 concentrations without clinical relevance, while an increase of heart frequency and sensation shortness of breath, light-headedness and headaches were recorded. This result indicates that an N95 mask covered by surgical mask induce discomfort in breathing, decrease in both mental and physical performance, accuracy and increased fatigue, especially during lengthy operations, and could cause elevated pCO2 levels.Two main conclusions emerge from this study: in healthy oral surgeons, wearing an FFP2 covered by a surgical mask for an extended period of time induces a reduction in circulating O