To explore the criteria, safety and efficacy of laparoscopic surgery in pediatric neuroblastoma (NB).A retrospective study of 87 patients with NB without image-defined risk factors (IDRFs) between December 2016 and January 2021 at Beijing Children’s Hospital was conducted. Patients were divided into two groups according to the surgical procedure.p = 0.013) and the time to start postoperative feeding after surgery (p = 0.002), the laparoscopic group was obviously better than the open group. Furthermore, there was no significant difference in the prognosis between the two groups, and no recurrence or death was observed.Between the 87 patients, there were 54 (62.07%) cases in the open surgery group and 33 (37.93%) cases in the laparoscopic surgery group. There were no significant differences between the two groups regarding demographic characteristics, genomic and biological features, operating time or postoperative complications. However, in terms of intraoperative bleeding (For children with localized NB who have no IDRFs, laparoscopic surgery could be performed safely and effectively. Surgeons who are skilled in this can help children reduce surgical injuries, speed up postoperative recovery, and obtain the same prognosis as open surgery.The online version contains supplementary material available at 10.1186/s12957-023-02997-9. Neuroblastoma (NB) is the most common extracranial solid tumor in children . The treWe reviewed all pediatric patients with NB who were treated at Beijing Children’s Hospital (BCH) between December 2016 and January 2021, and 87 patients with NB without IDRFs were included in this study. The children were divided into open surgery and laparoscopic surgery groups. The data obtained included sex, age at diagnosis, clinical manifestation, tumor location, tumor size, INRG, treatment strategy, operating time, intraoperative bleeding, and the time to start postoperative feeding. Tumor size was evaluated based on the largest diameter assessed on the latest preoperative computed tomography. The study was approved by the Medical Ethics Committee of Beijing Children’s Hospital (2017-k-89).In this study, chemotherapy was administered according to the guidelines for the diagnosis and treatment of NB 2019) published by the National Health Commission of the People’s Republic of China [ publishePatients with low- or intermediate-risk NB underwent resection of the primary tumor at the time of diagnosis or after three to four courses of chemotherapy. The patient was placed in a supine position, and the lower limbs were separated. The side with the tumor was padded at the level of the upper pole of the kidney. We elevated the side with the tumor to the 30° level by rotating the surgical bed. A 10-mm trocar was inserted through a 10-mm incision of the umbilicus using an electrotome to open the muscle layer. The abdominal cavity was insufflated with carbon dioxide to a maximum pressure of 10–12 mmHg, and gas flow was controlled at 0.5 L/min. Three additional 5-mm ports were inserted at these positions , and the rank sum test was used for intergroup comparisons. The classified variables were represented by the number (percentage), and the intergroup comparison was performed by the MYCN, 7 cases were amplified, 70 were not amplified, and 10 were unknown. According to the INRG risk group, 76 (87.35%) cases were very low risk, 3 (3.45%) cases were intermediate risk and 8 (9.20%) cases were high risk. According to the International Neuroblastoma Pathology Classification (Shimada System), 62 (71.26%) cases were classified as favorable histology, and 25 (28.74%) cases were classified as unfavorable histology. The comparison of clinical characteristics between the laparoscopic and open surgery groups showed that there were no significant differences between the two groups in terms of the International Neuroblastoma Risk Group, the International Neuroblastoma Pathology Classification, etc., which indicated that the prognoses of the two groups were comparable  females and 46 (52.87%) males, and the median age at diagnosis was 32  months. For the primary tumor site, 67 (77.01%) cases were from the adrenal, 15 (17.24%) cases were from the retroperitoneum, and 5 (5.75%) cases were from the pelvis. The largest tumor was 13.6 cm in diameter, and the median dimension of the tumor was 4.84 (± 2.69) cm. Based on the INRG staging system, 78 (89.66%) cases were classified as stage L1, 5 (5.75%) cases as stage M and 4 (4.59%) cases as stage MS. Regarding the status of In the 33 patients in the laparoscopic surgery group, according to the INRG risk group, 27 patients were in the very low-risk group, 3 were in the intermediate-risk group and 3 were in the high-risk group. Three cases were treated with preoperative chemotherapy, and 14 cases were treated with postoperative chemotherapy. In the open surgery group, 8 patients received preoperative chemotherapy, and 27 received postoperative chemotherapy.p = 0.013), time to start postoperative feeding (p = 0.002) and hospitalization expenses (p = 0.042); however, there were no significant differences in terms of operative time, intraoperative blood transfusion, hospital stay or postoperative complications . Specifically, the loss of blood volume during surgery in the laparoscopic group was 6.06  ml, and the mean time to start postoperative feeding was 2.83  days, which indicated that regarding intraoperative bleeding and postoperative recovery, the laparoscopic group was superior to the open group. In terms of postoperative complications, this study counted postoperative indicators of abnormal adrenocortical function, hemorrhage, intestinal obstruction, hypertension [In the laparoscopic group, three  cases were converted to open surgery due to the invasion of renal vessels. Regarding perioperative-related indicators Table , there w06 2.00, .00 ml, artension , pleuralrtension  and compAll patients were followed up until February 2022 in this study, with a median follow-up time of 31  months. Eighty-six patients survived without disease, and 1 patient in the open surgery group was lost to follow-up. There was no recurrence or progression in either group during the follow-up, and the 3-year overall survival rate and event-free survival rate were 100%.NB is the most common extracranial solid tumor in children, and surgery is the mainstay of treatment for localized NB. Because of its deep anatomical location and difficulty in exposure, NB has long been operated mainly by open surgery. However, with the development of laparoscopic technology, it has also been used more often in selective NB tumors. In some studies, laparoscopic surgery for smaller benign adrenal tumors (< 6 cm in diameter) has been shown to be safe and effective in terms of perioperative and long-term follow-up , 15. MarRegarding the indications for the application of laparoscopic surgery for NB, most studies have focused on tumor size and vascular encasement. It has been suggested that laparoscopic resection is safe and effective for NB with a tumor diameter < 2 cm . P. De LThe application of laparoscopy for the treatment of malignant solid tumors may have the possibility of incisional implantation or metastasis, which is more frequently reported in adults , 22. Incp = 0.013). Children in the laparoscopic surgery group started eating earlier than the children in the open surgery group (p = 0.002). This will allow children with NB to receive faster nutritional support and earlier postoperative chemotherapy. Laparoscopic surgery also allows for maximum organ preservation. In the laparoscopic group of this study, there were two cases with bilateral NB; in one case, both adrenal glands were preserved, and in the other case, due to the large tumor on the right side, approximately 3.5 cm in diameter, there was no obvious residual adrenal gland, and only part of the left adrenal gland was preserved.In general, laparoscopic surgery is characterized by a short operative time, fast recovery, low incidence of bowel adhesion formation decreases, and better cosmetic appearance , 8, 24. Regarding prognosis, there were no significant differences between the open and laparoscopic groups in this study. All 33 patients in the laparoscopic group underwent complete resection of the primary tumor. The 3-year EFS and OS of these children were both 100%, which may be related to the high proportion of very low-risk children (27/33) and the short follow-up period. On the other hand, it shows that laparoscopic surgery for NB with no IDRFs is effective and does not raise the risk of local recurrence of the tumor. Similar results have been reported by Marc-David Leclair et al.  in a mulFor children with stage MS NB, laparoscopic surgery allows not only resection of the primary tumor but also liver biopsy. Three (3/9) children with MS stage underwent laparoscopic liver biopsy in this study. The choice of position and incision for patients requiring liver biopsy differs from that for simple resection of adrenal tumors. For resection of the adrenal tumor alone, we can choose the lateral position. If liver biopsy is desired, the supine position is a better choice, and the surgery requires additional incisions. Laparoscopic adrenal tumor resection via the retroperitoneal approach is technically mature and has been reported in related cases , 25, butHowever, this study was a single-center retrospective study with no randomization in the choice of laparoscopic treatment. In the past, our decision to perform laparoscopic surgery was mainly based on the IDRFs, tumor size, and experience of the surgeon, there existed selection bias. The follow-up of this study was also not long enough. The indication of choosing laparoscopic surgery for NB and the impact of laparoscopic resection on NB postoperative metastasis, recurrence and long-term survival still need to be validated in prospective clinical trials with large samples.For children with localized NB who have no IDRFs, laparoscopic surgery can be performed safely and effectively. Tumor size may not be a significant factor limiting the use of laparoscopy. It has equal recurrence and survival rates compared with open resection and provides some advantages of minimally invasive surgery.Additional file 1: Supplementary Table 1. Descriptions of Image-Defined Risk Factors.Additional file 2: Supplementary Table 2. Classification of Surgical Complication.


Fixed prostheses are appropriate treatment solutions for edentulous patients. In fixed prostheses, following “All on four”, titanium frameworks are commonly used to support the implants. However, the limitations of titanium have prompted researchers to search for alternative materials (e.g. polymers). This study applied finite element investigation to evaluate the stress distribution in the parts of fixed prosthesis and the surrounding bone tissue, using polymeric frameworks in place of titanium, and different densities of spongy bone. As, the success of fixed prosthesis was predicted to be influenced also by bone quality, particularly spongy bone density. Fixed prosthesis was constructed on edentulous mandible, then different frameworks  were stimulated instead of titanium, under 300N unilateral and bilateral forces. Three densities of spongy bone were stimulated which are normal, low and high. The choice of framework material depended on the density of spongy bone. Moreover, PEEK framework showed the lowest stress values on bone tissues and the highest stress values on mucosa. All frameworks could be used in the fixed prosthesis, in the cases of normal and high densities of spongy bone. In low-density case, soft frameworks (PEKK and PEEK) were recommended to reduce the stresses generated on bone tissues. These prostheses utilize “All-on-4” concept which reduces the treatment time and the risk of morbidity, overcomes the complicated prosthetic and surgical problems caused by anatomical limitations, and also improves eating, speaking, and self-confidence3. Moreover, the "All-on-4" prostheses are characterized by their high success rates and easy care routines. The drawbacks of "All-on-4" are relatively minor and can be overcome. These drawbacks are presented by their relatively high costs and poor hygiene complications which are rare occurrences4.Due to the current drawbacks of traditional complete dentures, implant-supported fixed prostheses have recently been employed as appropriate solutions for edentulous patients to restore the quality of life4. Till now the material of choice for implants is titanium due to its rigidity, strength, excellent corrosion resistance, and biocompatibility with the bone and gum tissues. Titanium, on the other hand, has drawbacks, including aesthetic impairment, metallic taste, and incompatibility with imaging techniques5. As a possible alternative to titanium, zirconia implants have been recently used because of their high mechanical stability, biocompatibility, low plaque affinity, and white “tooth-like” colors6. However, other researchers have recommended the usage of polymeric implants (e.g. PEEK) because of their elastic modulus which is close to the bone, and their shock-absorbing abilities8. Despite the drawbacks of titanium, long-term reports about clinical survival rates have made titanium the “gold standard” material over other materials for the manufacturing of endosseous dental implants10. Histological studies have shown the complete integration of titanium implants with bone tissue, as they can physically bond to bone tissues and hence last longer even if subjected to high stresses, compared to their alternatives10.In “All-on-4”, four implants are placed in the edentulous jaw for supporting the loaded prosthesis, without the requirement for bone augmentation3. In fixed prostheses, one of the key factors for long-term clinical success is the correct choice of the superstructure (framework) material that supports the implants and artificial teeth, and transfers the load to the substructures including the bone tissue12. Many clinicians want to find suitable framework materials that overcome biomechanical deficiencies while also improving function, aesthetics and the primary stability of the fixed prosthesis. Metallic materials (e.g. titanium) are commonly employed in the manufacturing of frameworks due to their durability, biocompatibility, and great corrosion resistance5. However, the patients' desire for using low-cost metal-free prostheses has prompted researchers to look for alternate materials.In “All-on-4”, a framework is attached to the titanium implants through the multi-unit abutments to support them and enhance the load distribution, reducing the stresses transferred to bone tissues and mucosa. On the framework, acrylic artificial teeth are assembled and secured using acrylic material13. These materials are biocompatible and radiolucent, with low densities, strong shock absorption abilities, high chemical erosion resistances, and good aesthetic appearances. The mechanical properties of PEEK can be improved to suit the biological demands by adding carbon fibers (CFR-PEEK) in a certain percentage14. Carbon-fiber-reinforced polyetheretherketone (CFR-PEEK) composites have historically been used in the production of bone fixation screws, spinal cages, cardiac and neurological leads, and knee replacement products15. Recently, they have been successfully used in dentistry because of their biocompatibility, and mechanical durability16. These composites are expected to be used widely in dentistry in the fabrication of different prosthetic parts, as alternatives to stainless steel and titanium materials. To fabricate a part, CFR-PEEK sheets (30% or 60%) can be heated above their melting temperature and then pulled over or pushed into a mold with either vacuum or pressure17. Although polymeric materials have been employed in dentistry and orthopedics, further studies are needed to determine whether they can be used in the fabrication of frameworks.PEKK (polyether ketone ketone) and PEEK (polyether ether ketone) are two new polymeric materials that have recently been introduced in dentistry for the manufacture of implants, abutments, and removable and fixed prostheses19.The primary stability of fixed prosthesis is expected to be influenced by bone quality, as it influences the distribution of loads in all parts. Following edentulism, bone loss is a common occurrence, in which the old bone breaks down quicker than the new one grows, reducing bone density and hence strength. Too much bone production, too little bone resorption, or too much vitamin D in the body, on the other hand, enhances bone density and strength. The researchers also have revealed that the spongy bone is more susceptible to bone loss or gain than the cortical bone. Low and high densities for spongy bone are defined from CT scans as 150 and 850 Hounsfield units [HU]20. In this study, the finite element method was utilized to investigate the effect of using novel polymeric frameworks  as alternatives to titanium framework in the fixed prostheses to overcome its limitations. This study also investigated the effect of spongy bone density on the stability of prosthesis and the selection of framework material. 300 N unilateral and bilateral forces were applied vertically to stimulate the different mastication mechanisms. The null hypothesis predicted that the polymeric frameworks would exhibit the lowest stresses in bone tissues and represent the best scenario, in comparison to the titanium frameworks. Additionally, these polymeric frameworks would be appropriate for use with both high and low densities of spongy bone, not only in the normal density case.The finite element analysis has gained popularity in dentistry due to its ability to model complex geometries and provide important information regarding the distributions of stresses/strains in prosthetic parts, surrounding tissue, and boneTables Under bilateral forces Table , the maxFor the three cases, the highest stress values on implants were found by utilizing CFR-PEEK 60% frameworks, as shown in Tables Under bilateral force, by using CFR-PEEK 30%, PEKK, and PEEK frameworks, the reductions in the stresses of implants were  in the-normal density case,  in the high-density case and  in the low-density case, in comparison to titanium framework.Tables Under bilateral force, by using titanium frameworks, the max stresses on mucosa were (0.086 MPa), (0.074 MPa), and (0.11 MPa) in normal, high, and low densities cases. These values were increased to (0.135 MPa), (0.126 MPa) and (0.155 MPa) by using PEEK frameworks, however, reduced to (0.083 MPa), (0.07 MPa) and (0.106 MPa) by using CFR-PEEK60% frameworks.Figures For all three cases, under unilateral and bilateral forces, the lowest values of peak max and min principal stresses of cortical bone were recorded in the high-density case, followed by the normal-density case and the low-density case Tables , 4. In aUnder unilateral force, in the normal-density case, the max principal stress on cortical bone was reduced by 1, 1.61 and 2.11% by using CFR-PEEK 30%, PEKK, and PEEK frameworks, compared to titanium. Besides, the min principal stress was reduced by 1.45, 3.55, and 5.06% respectively. In the high-density case, for CFR-PEEK 30%, PEKK, and PEEK frameworks, the value of max principal stress was reduced by 1.6, 2.4, and 2.97%, compared to titanium. In addition, the value of min principal stress was reduced by 3.37, 5.04, and 5.57%. In the low-density case, the values of max and min principal stresses for cortical bone were nearly unchanged. For spongy bone, using CFR-PEEK 30%, PEKK, and PEEK instead of titanium, the max principal stress was reduced by  in the normal-density case,  in the high-density case, and  in the low-density case, as illustrated in Table Under bilateral force Table , in the Figures 21) to assess the primary stability of the fixed prosthesis. Under unilateral force, implant 1 (loaded side), as seen in Fig. Using the three cases of cancellous bone density, the maximum total displacement values (μm) of the four implants were retrieved and compared with the critical limits (50–150 μm24. The finite element method (FEM) is a numerical method of analyzing the stresses and strains at any point. It has several advantages over other techniques in dentistry, including the ability to accurately represent complex geometries, make modifications, suggest new designs, specify multiple boundary conditions, stimulate various materials, and then quickly calculate the internal stresses and strains at any point20.The stress–strain analysis is a branch of engineering that utilizes different techniques to determine the stresses and strains in materials and structures, under different loading conditions. The photoelastic technique, digital image correlation technique, electrical resistance strain gauge, and finite element method have been commonly employed in dentistry in the stress–strain analysis25, a 3D model of a mandible with a fixed prosthesis was constructed and stimulated with different frameworks, using only the normal case of bone density. The simulation results demonstrated that the polymeric frameworks could be used instead of titanium in the fabrication of the hybrid prostheses.This study used the finite element method to conduct stress analysis on edentulism mandible rehabilitated with a fixed prosthesis, using different frameworks. The study focused on the new polymeric frameworks  to be used as alternatives to the protocol titanium frameworks, besides revealing their effects on the biomechanical performance of the fixed prosthesis. Different densities of spongy bone were stimulated to choose the appropriate framework material for each bone condition. In Shash et. al's research26 and studies30, the maximum von Mises stresses were calculated for prosthetic parts (frameworks and implants) because of their ductile properties. In the mandible, the cortical bone is much stiffer and stronger than the spongy bone, while the spongy bone is more flexible and ductile. According to the failure theory of principal stress26 and like other studies32, the maximum (tensile) and minimum (compressive) principal stresses were extracted for cortical and spongy bones and compared to the permissible tensile and compressive strengths  in the fabrication of frameworks. They hypothesized that stiff superstructures would transfer fewer stresses to the substructure parts36. Other authors37 recommended utilizing soft superstructures to dampen the stresses conveyed to the substructure parts.The framework material influenced the stresses generated on all prosthetic parts and bone tissues in studies13. These materials are biocompatible in vivo and in vitro and radiolucent, with good mechanical, chemical, thermal, and electrical properties , and good aesthetic appearance. Besides, they have neither toxic effects nor clinical inflammation. Due to their structures, low elastic modulus (3–5 GPa) and high shock-absorbing abilities, these materials are expected to solve the stress-based problems on bone tissues. As they can evenly distribute the stresses generated during mastication on the substructure parts and hence reduce the stresses transferred to bone tissue28.PEKK and PEEK are polymeric materials, which have recently been used in dentistry in the fabrication of implants, abutments, fixation screws, etc. as alternatives to metals and ceramics13. PEKK has recently been employed in restorative, prosthetic, and implant dentistry, because of its superior mechanical strength, shock absorbing ability, low density, and the presence of the second ketone group which enables more surface modification. PEKK material has been introduced as a promising alternative material for long-term orthopedic applications over titanium. Since it offers excellent biocompatibility, and metal-free restorations and is thus helpful in patients with allergies13.Polyether ketone ketone (PEKK) is a novel polymeric material that has attracted the attention of researchers because of its excellent properties that make it suitable for a variety of uses 8. Moreover, it is lighter than metal and more comfortable for patients. The short-term report38 clarified that PEEK-resin prosthesis utilizing "All-on-4" concept, was a viable option for edentulous patients, although they still need long-term evaluations. In addition, the use of PEEK as a framework for a fixed partial denture (FPD) produced very good results with a high level of patient comfort and acceptability, according to Sinha et al.'s case study39. Hence, clinically, PEEK material is a premium innovative prosthetic solution for either fixed prostheses, removable or screwed-in.PEEK material is a high-performance polymer that has been tested in many medical fields, under different conditions. The tests demonstrated that PEEK material possessed a higher strength-to-weight ratio which is especially important for dental parts. It can also handle abrasive and compressive forces without losing its integrity and durability28 extracted the max and min principal stresses generated on normal bone density, using PEEK and titanium frameworks, on the maxillary prosthesis utilizing "All-on-4". The results demonstrated that PEEK material produced the lowest stresses on the bone under unilateral force. The max principal stresses on cortical bone were 23.2 and 34.3 MPa by using PEEK and titanium, while the min principal stresses were 39.5 and 68 MPa respectively. In the current study, in the normal-density case, the values of max principal stresses on cortical bone were 17.67 and 18.05 MPa using PEEK and titanium respectively, while the min principal stresses were 42 and 44.24 MPa. Chen et al.40 also conducted finite element analyses of the mechanical performance of four removable partial denture designs, utilizing cobalt chrome, titanium alloy, and PEEK frameworks. The findings demonstrated that the PEEK framework caused the lowest stress on the framework, the lowest stress on the periodontal ligament, and the maximum mucosal stress when compared to cobalt chrome and titanium frameworks.In finite element investigations, Haroun et al.14. The elastic modulus of PEEK is about 3.5 GPa, and the addition of carbon fibers with a certain percentage increases the elastic modulus to 18–150 GPa. These composites have recently been used in dentistry due to their strength, resistance to chemical erosion, compatibility with imaging techniques, and high inertness16. There have been several studies that have evaluated the performance of CFR-PEEK material in a variety of orthopedic implants, under different testing techniques. Most articles have reported positive findings regarding the properties, technical outcomes, durability, and safety of CFR-PEEK in orthopedic implants42.PEEK properties can be improved to be used in dentistry by the addition of carbon fibers44, while others46 have shown no significant correlations. Marquezan et al.43 and Hsu et al.44 demonstrated that spongy bone density played an essential influence on prosthetic stability.The choice of framework material was also expected to depend on the bone quality to maintain the prosthesis stability. Some studies found a correlation between bone density and prosthesis stability47), indicating no occurrence of mucosal inflammation.In this study, the null hypothesis—assuming that the polymeric frameworks would exhibit the lowest stresses in bone tissues and represent the best scenario, in comparison to the titanium frameworks—was partially accepted. The results illustrated that CFR-PEEK 30%, PEKK and PEEK frameworks reduced the stresses on implants and bone tissues, however, increased the mucosal stress, in comparison to titanium framework, unlike CFR-PEEK 60%. The results illustrated also that the spongy bone density affected the stresses generated on all parts especially mucosa, and bone tissues, for all the used frameworks. In the low-density case, the decrease in spongy bone density decreased the spongy bone stress and thus increased the stresses on cortical bone and mucosa, while the opposite occurred in the high-density case. From the extraction of results, no failure might occur in all frameworks and implants as their max stresses did not surpass their yield strengths Table . The res26. For cortical bone, with normal density, the allowable tensile and compressive limits are (66.6 & 93.3 MPa), using a 1.5 safety factor. For spongy bone, the allowable tensile and compressive limits are nearly (2 &2.33 Mpa), (6.5 &10.5 Mpa), and (10 &15 Mpa) for low, normal, and high densities49. Tables The maximum and minimum principal stresses were extracted for bone tissues, and compared with the tensile and compressive strengths, according to the failure theory of principal stress 66.6 & 9.3 MPa, u21) in order to evaluate the primary stability of the prosthesis. Due to the possibility of fibrous tissue forming between the implant and the bone, displacements higher than 150 μm must be avoided21. All of the implants in this investigation showed displacements that were less than 50 μm, demonstrating the prosthesis stability.The displacements of implants were also extracted in this study using all frameworks and compared to the threshold  slightly reduced the stresses on bone tissues, however, increased the mucosal stress.CFR-PEEK 60% distributed the stresses in a similar manner as the titanium framework.All frameworks could be used as alternatives to titanium in normal and high densities cases.In the low-density case, soft materials were preferred as they decreased the stresses generated on bone tissues.Within the limitations of the study, the following were concluded:In vivo, polymeric frameworks are anticipated to offer numerous major benefits over titanium, including enhanced performance and aesthetics, improved design freedom, production of lighter prostheses, reduced overall cost, and reduced production problems and the risk of mechanical problems. However, additional investigations and long-term studies are needed in near future.50. The mandible model was imported as a solid cortical bone with a symphysis height of 30 mm, as shown in Fig. A 3D model of a female edentulous mandible was built using an OBJ file imported from "BodyParts3D/Anatomography" website 51). Posteriorly, two implants were modeled with a diameter of 4.1 mm and a length of 11.5 mm and placed with an angle of 30 into the second premolar region. Anterior implants were fitted with straight multi-unit abutments which did not engage the internal hex connections, while posterior implants were fitted with angled multi-unit abutments . Four titanium copings (sleeves) were mounted over the anterior and posterior abutments using mini screws with 1.25 mm diameters.Following “All‑on‑4” concept, anteriorly, vertical implants were modeled with a diameter of 3.7 mm and a length of 10 mm, in the lateral incisal area based on the dimensions imported from ZIMMER catalog  as presented in Fig. 53. Complete osseointegration between implant and bone surfaces was assumed, and all parts were assumed to be perfectly bonded together through the contact surfaces.A horseshoe-shaped framework  was attached to the four copings. Then twelve acrylic teeth were arranged on the framework and secured with acrylic material Fig. . The fix54. The materials used in this study , using “adaptive” function with (0.2–1 mm) elements sizes. A mesh refinement was established based on the 10% convergence test. The numbers of nodes and elements in each part were presented in Table 55. In this research, 300N vertical force was applied to the three posterior teeth to stimulate unilateral  and minimum principal stress (Pmin) were computed for bone tissues due to their ductile and brittle properties. Prosthetic components, implants and mucosa were considered as ductile materials and hence their von Mises stresses were calculated. To check the primary stability of the fixed prosthesis, the total displacement of implants was investigated.


Pre- and post-exercise intervention assessment included body weight (BW), waist circumference (WC), hip/waist ratio (H/W), Homeostasis Model Assessment Insulin Resistance (HOMA-IR), blood lipids, and steatosis indices. Fatty Liver Index, Lipid Accumulation Index, WC, H/W, triglycerides, and total cholesterol were improved (p < 0.05) post-exercise, while no differences (p > 0.05) were observed in BW, HOMA-IR, HDL, LDL, Hepatic Steatosis Index, and Framingham Steatosis Index compared to pre-exercise values. It is concluded that a 7-day combined exercise program can have beneficial effects on hepatic steatosis and central adiposity indices, independently of weight loss, in patients with NAFLD.Non-alcoholic fatty liver disease (NAFLD) is a very common liver disease associated with obesity, unhealthy diet, and lack of physical exercise. Short-term aerobic or resistance exercise has been shown to result in reduced liver fat in patients with NAFLD; however, the impact of the combination of these types of exercise has received less attention. This study investigated the effect of a short-term (7 days) concurrent exercise training program performed daily on liver steatosis indices, as well as the glycemic and lipidemic profile of overweight/obese sedentary volunteers. Twenty adult patients (age: 47.3 ± 12.3 yrs, body mass index: 32.4 ± 3.4 kg/m Non-alcoholic fatty liver disease (NAFLD) is a condition in which fat accumulates in the hepatocytes (steatosis), with this fat accumulation not associated with chronic alcohol intake. Non-alcoholic steatohepatitis (NASH) is the next stage of NAFLD, where, in addition to steatosis, an inflammatory condition develops that gradually leads the hepatocytes to apoptotic cell death. As a chronic state of liver inflammation, NASH eventually results in liver fibrosis and, if the disease progresses, its pathological mechanisms drive the deterioration into the stages of liver cirrhosis and liver cancer ,2. The iIt is noteworthy that there is no FDA-approved drug treatment for NAFLD and the therapeutic tools that have been proposed include regular physical activity, the adoption of a balanced diet, and weight loss courses . Indeed,The lifestyle changes usually lead to a reduction in body weight that seems to be a key factor to improve the condition. Specifically, research has shown that a 5% body weight loss with exercise and diet can reduce steatosis levels in NAFLD and reverse histological changes in stages of fibrosis and hepatocyte necrosis , while a−2) and diagnosed with NAFLD by ultrasound and blood biomarkers, while 10 of them were under pharmacological treatment for coexisting metabolic dysfunctions . In particular, three participants were receiving a single therapy, four participants were receiving double, two participants triple, and one participant quadruple pharmacological therapy. Throughout the study, these patients continued to take their medication as prescribed by their physician  and a medical clearance was provided before exercise testing. The study had received the approval of the Ethical Committee of the University and all procedures were in accordance with the Helsinki declaration of 1975, as revised in 1996.After a 12 h overnight fast, participants underwent baseline assessment that included hepatic ultrasound, biochemical blood testing, and OGTT. On the following day, somatometric measurements were taken and the volunteers performed an incremental cycling exercise test to volitional fatigue to establish a workload–heart rate (HR) relationship to be used for the exercise training. Afterwards, participants performed three different resistance exercises to estimate their individual one-repetition maximum (1-RM). For the next 7 consecutive days, volunteers followed a concurrent exercise training program (see details below). On the day following completion of the training program, again after a 12 h overnight fast, hepatic ultrasound, blood testing, OGTT, and somatometric measurements were repeated.After a 12 h overnight fast, participants arrived at the laboratory between 7:30–08:00 a.m. and hepatic ultrasound  examination was performed by an experienced physician who was not aware (blind) of the purpose of the study. Then, baseline blood sampling and the OGTT were performed. Specifically, with the participants sitting quietly, a 10 mL venous and duplicated 25 μL of capillary blood samples were collected. Afterwards, 75 g of glucose  dissolved into 300 mL of water were administered to the participants. At 15, 30, 45, 60, 90, and 120 min after glucose ingestion, duplicate 25 μL of capillary blood samples were collected from each volunteer. On the following day, participants visited the lab after having their last meal at least 4 h earlier and body mass , height , and waist and hip circumference (using a flexible tape) were measured. Then, volunteers performed an incremental cycling exercise test  to fatigue to determine the exercise intensity equivalent to 75–80% of HR maximum (HRmax) to be used for the aerobic exercise training. Heart rate was measured by telemetry . The initial workload was 30 watts for 3 min and exercise intensity was increased by 30 watts every 3 min until participants were unable to maintain a pedal speed of 50 revolutions/min. Using regression analysis, the exercise intensity corresponding to 75–80% of HRmax was estimated. After a 15 min passive recovery, participants practiced the correct execution technique before performing three basic exercises  in resistance exercise machines  to estimate 1-RM. A 10 min rest was allowed between each 1-RM estimation cycle. In the 1-RM estimation testing, three sets were used, one for warm-up (8–10 repetitions) with a light weight, one at 50–70% of perceived 1-RM, and one set for 1-RM estimation, with 2 min rest between the first and second set and 3 min between the second and third set. In the 1-RM estimation set, volunteers were instructed to exert maximal effort, and no more than 8 repetitions (range 4–8 repetitions) were performed by any participant. The weight lifted and the repetitions achieved were used to estimate 1-RM . After cAll participants followed a supervised exercise training protocol that combined aerobic and resistance exercise for 7 consecutive days. Each exercise session lasted for 60 min, beginning with a 5 min warm-up cycling at 60% HRmax, followed by 20 min of resistance exercise at 65–75% of 1-RM and 30 min of aerobic exercise at 75–80% of HRmax performed on a cycle ergometer , and completed with a 5 min cool down. Regarding resistance training, each day, volunteers performed in circuit four exercises targeting one of the following main muscle groups: chest , back , or lower limbs , completing two sets of 10 repetitions each, with 1 min rest between sets. A broad range of equipment was used, i.e., cables, fitness ball, resistance bands, dumbbells, and exercise mat. On day 4 of the exercise intervention, patients followed a milder exercise protocol consisting only of 30 min aerobic exercise at 75–80% of HRmax, while on days 5, 6, and 7 the exercise protocols of day 1, 2, and 3 were repeated, respectively.g for 4 min and stored at −80 °C for further analysis. The two deproteinized supernatants obtained for each time point were analyzed in duplicate on a microplate reader  for blood glucose . Using the trapezoidal rule, the total area under the blood glucose–time curve (AUC) was calculated from the blood glucose data obtained at the different time points during the OGTT. A total of 2 mL from the venous blood sample was used for the determination of platelets (PLT) count and glycated hemoglobin (HbA1c) . The remaining venous sample was left to clot for 30 min and centrifuged at 1500× g for 10 min. Serum was separated and divided into aliquots of 500 μL and stored at −80 °C for subsequent analysis, with the exception of one aliquot that was used fresh for the determination of low-density lipoprotein (LDL) cholesterol , according to the manufacturer’s directions, on an automatic analyzer . Serum insulin was determined using an electrochemiluminescence immunoassay kit  on an automatic analyzer . Serum AST, ALT, γ-glutamyl transferase (γ-GT), C-reactive protein (CRP), albumin (ALB), glucose, triglycerides, total cholesterol (TC), and high-density lipoprotein (HDL) cholesterol were analyzed on an automatic analyzer , using commercially available kits .Capillary blood samples were dispensed into Eppendorf vials containing 250 μL of 2% perchloric acid, mixed well, centrifuged at 1500× Before and after the exercise training intervention, the homeostatic model assessment for insulin resistance (HOMA) , the hepParticipants were required to refrain from any physical activity two days before the baseline measurements and follow the same diet on the day before baseline blood testing and post-intervention blood testing. In addition, volunteers were not allowed to participate in any physical activity during the intervention period other than the supervised exercise training program of the study.p < 0.05.Data were analyzed using SPSS . The Shapiro–Wilk test was used to assess the normality of the data. The Wilcoxon Signed Rank test was used to examine the effect of exercise intervention (pre- vs. post-intervention measurements) on HbA1c, AST, γ-GT, CRP, FIB-4, HDL, AST/ALT ratio, waist and hip circumference, HOMA index, and the hepatic steatosis FLI and fibrosis NFS indices. The remaining variables were analyzed using a two-tailed paired t-test. Effect size was estimated by calculating Cohen’s d (d) in t-tests and r in Wilcoxon Signed Rank tests. In case of significance, 95% confidence intervals (CI) of the means (t-test) and medians (Wilcoxon) differences were also reported. To estimate the sample size, G*Power v. 3.1.9.7 was used. Utilizing the HOMA-IR model data from the study by Haus and colleagues , before The effects of a short-term, daily, concurrent exercise program on liver steatosis indices, as well as on glycemic and lipidemic profile of overweight/obese patients with NAFLD, were examined in this study.p = 0.456; n = 19) at the end of the 7-day exercise intervention compared to baseline measurements in the NAFLD patients. Similarly, no significant improvements were found in HbA1c levels , fasting insulin levels , and the HOMA index  after the completion of the 7-day intervention. Similarly, no changes were observed in AST, ALT, γ-GT, CRP, and albumin levels as a result of the 7-day exercise intervention program , and neither was the AUC .There were no significant changes in HDL  and fast program . FurtherInterestingly, however, significant improvements were observed in triglycerides, which also probably contributed to the observed reduction in total cholesterol post-exercise. Furthermore, reductions were found in waist circumference, hip circumference, and in the waist/hip ratio after the exercise intervention, though no significant improvement was found in the patients’ body weight .Moreover, hepatic steatosis indices LAP and FLI significantly improved after the 7-day exercise program, while no significant changes were found in the hepatic steatosis indices HIS and FSI, as well as in hepatic fibrosis indices FIB-4, NFS, and AAR at the end of the short-term exercise intervention .This study investigated the potential changes in liver steatosis indices, as well as in the glycemic and lipidemic profile of overweight/obese patients suffering from NAFLD, following a short-term concurrent training program performed daily, without any accompanying dietary intervention or intentional body weight loss. The main finding of the study was that a 7-day exercise program that combines aerobic and resistance components can improve hepatic steatosis and central adiposity indices in patients affected by NAFLD regardless of body weight loss. Since advanced fibrosis was not present in the participants of this study based on the baseline scores of hepatic fibrosis indices FIB-4, NFS, and AAR, no significant changes were found in these scores after the completion of the short-term exercise training, as expected.Specifically, after the one-week exercise intervention, hepatic steatosis, as assessed by the indices LAP and FLI, improved, while other indices such as HSI and FSI showed no significant improvement. The fact that each steatosis index is based on different variables may explain this “partial” improvement of steatosis in this study. LAP and FLI indices are based on triglycerides levels and waist circumference, which were found to improve following exercise training, while HSI and FSI evaluate glycemic and metabolic factors as well, such as the presence of type 2 diabetes. In addition, the reduction in triglycerides, in turn, had an influence on total cholesterol, which also decreased after the exercise intervention. Nevertheless, the significant decline in indices associated with hepatic steatosis found in this study is of major importance, since it is also associated with a reduction in risk of cardiovascular complications ,31 whichp = 0.11) following the exercise intervention. We assume that the combination of aerobic and resistance training utilized in this study might cause a higher metabolic stress, as opposed to the aerobic exercise training used in the previous short-term protocols that failed to engender clear glycemic benefits after the short exercise intervention. These glycemic responses might also be a result of possible muscle damage which the resistance exercise could have caused the sedentary patients of our study. Indeed, previous studies have shown a reduction in insulin sensitivity because of a strong inflammatory response and a decrease in glucose transporter GLUT4 following exercise-induced muscle damage [Although the combination of resistance and aerobic exercise would be expected to result in an improvement of the glycemic profile of the patients, no significant alterations were found in this study. Specifically, the levels of fasting plasma glucose and fasting insulin, as well as HOMA-IR index, did not change after the completion of the 7-day exercise program. Regarding the effect of a short 7-day exercise program on fasting plasma glucose and insulin concentrations in NAFLD patients, results are conflicting even for similar studies from the same laboratory, reporting either no change ,19 or ane damage , which me damage ,38,39,40Another reason for the discrepancy between the present and the other studies that have also employed a short 7-day exercise protocol in NAFLD patients ,19,20,21In terms of somatometric characteristics, body weight and BMI did not change in the overweight/obese patients with NAFLD after the completion of the short-term exercise protocol. This finding has also been observed in other studies of similar duration ,19,20,21The main limitation of the present study was that there was no control group. Ideally, a group of obese individuals with similar BMI and NAFLD indices to the exercise group should have been evaluated without participating in any form of exercise or physical activity. Some of the metabolic indices examined were in fact interconnected, influencing each other, such as triglycerides and total cholesterol. In addition, the examination of inflammatory cytokines and oxidative stress indices would have provided valuable information regarding the effects of a short-exercise combination program on these factors. Furthermore, a larger sample size would have added more power to the data obtained. Finally, the use of magnetic resonance spectroscopy would have provided important information regarding intrahepatic and visceral fat content.In this study, we provided information about changes in liver steatosis, glycemic, lipidemic, and somatometric indices in response to a daily, concurrent exercise training program in patients with NAFLD. These changes could be potentially involved in a complex network of physiological processes associated with exercise-induced metabolic adaptations in overweight/obese patients. We revealed that a 7-day combined exercise training may be beneficial with respect to hepatic steatosis and central adiposity indices, independently of weight loss of the patients. More studies are needed to further characterize the physiological signature of metabolic adaptations to short-term exercise training in humans. Such a characterization could contribute to a better understanding of the adaptation mechanisms following exercise in patients with metabolic disorders and to the development of treatment strategies targeting the various components of the aforementioned network of adaptive physiological processes. Indeed, the ability of metabolic mechanisms to rapidly adapt to daily exercise might have clinical applications, as a short-term concurrent exercise that would directly trigger beneficial effects on hepatic steatosis and lipid metabolism could be used as an effective strategy to manage lipid disorders.


The prevalence of overweight and obesity is continuously increasing, both in the adult and pediatric populations, posing a substantial challenge to public health. Understanding the epidemiological burden of metabolic syndrome (MetS) among children, particularly regarding its complications and long-term effects in adulthood, is crucial for identifying effective preventive measures and enhancing the clinical care of obese children. Therefore, by searching two databases, a systematic review was conducted in order to evaluate studies that specifically addressed the epidemiological MetS impact among overweight/obese European children and adolescents. Overall, 15 studies were considered. The epidemiological data concerning the MetS impact were contingent on the diagnostic criteria used and varied across countries, resulting in a prevalence range of 1.44% to 55.8%. Spanish studies were the most numerous (34%), revealing a country prevalence rate ranging from 2.5% to 19.6%. Males  and subjects with overweight/obesity  were mainly affected. Obesity emerged as the main risk factor in the MetS development and the consequent onset of cardiovascular complications and diabetes. Knowing the MetS burden and its risk factors could improve their prevention, detection, and treatment, and guide the development of targeted public health interventions to appropriately address the health needs of younger patients. Today, the prevalence of overweight and obesity has become a progressively widespread issue, affecting not only adults but also the younger population.It is estimated that approximately 39% of the global population is facing challenges related to excess weight, with a gradual rise in the prevalence of overweight conditions among children and adolescents .Since 1980, the occurrence of childhood obesity has more than doubled in over 70 countries . Recent This trend is a significant public health concern that demands serious attention. Having excessive body weight is linked to a heightened susceptibility to cardiovascular disease (CVD), type 2 diabetes (T2DM), and metabolic syndrome (MetS), especially when body fat is localized in the abdominal area and when obesity begins in childhood .Over the years, MetS, a complex disorder characterized by the coexistence of several risk factors, including dyslipidemia, central obesity, and/or insulin resistance (IR), hypertension, and dysregulated glucose homeostasis, has been extensively investigated in the adult population . HoweverUntil the present time, a global consensus on the diagnostic criteria for MetS in the pediatric population has not been reached; in most cases, the criteria applied to the adult population are adapted to children, but with different cut-off values. However, the currently available definitions of MetS  that havHence, the primary goal of our review was to present a comprehensive synthesis of the available literature concerning the epidemiological burden of MetS among overweight and obese European children and adolescents, while also highlighting the disparities among the commonly employed definitions. Despite the absence of a universally standardized definition, our analysis aims to identify persistent gaps in the field of MetS diagnosis, as well as delineate the cluster of risk factors that predominantly contribute to its onset. This endeavor has the potential to facilitate the development of a life-course public health approach, thereby supporting the design of effective preventive strategies targeting this vulnerable young population.A systematic literature review was carried out, and the findings were presented following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) . HoweverThe process of the literature search involved consulting two databases, namely PubMed and Web of Science (WoS). The following search string was used on PubMed: ((“epidemiologies” [All Fields] OR “epidemiology” [MeSH Subheading] OR “epidemiology” [All Fields] OR “epidemiology” [MeSH Terms]) AND (“metabolic syndrome” [MeSH Terms] OR (“metabolic” [All Fields] AND “syndrome” [All Fields]) OR “metabolic syndrome” [All Fields])). This search string was adapted for WoS. Filters were applied to include only English language articles, those published between 1 January 2012 and 1 April 2023, involving the target population (children: birth–18 years), and studies on humans. The search was launched on 1 April 2023.The identified articles were organized in an Excel datasheet and subjected to a screening process based on predefined inclusion and exclusion criteria. Duplicate articles were identified and removed. The screening initially involved evaluating the titles and abstracts, followed by a review of full-text articles.The review question was defined according to the PICO  framework. In brief, the goal was to identify all studies investigating the epidemiological burden of MetS in children and youths affected by overweight and obesity.Inclusion criteria were: (1) study population included children and adolescents (age range 0–18 years) with overweight and obesity, (2) original articles and systematic reviews, (3) articles written in English and (4) conducted in European countries, and (5) published between 1 January 2012 and 1 April 2023.Exclusion criteria were: (1) only adult population (>18 years old) studied, (2) non-European contexts, (3) studies conducted in animals or in vitro, and (4) narrative reviews, commentaries, editorials, conference presentations, letters to editors, and citations without full text.Three researchers  independently conducted the initial screening of titles and abstracts, followed by a review of full texts. Disagreements were either resolved through discussions or by engaging a senior researcher (G.E.C.).The information extracted from the articles that were definitively included into the literature review encompassed details such as the name of the first author, year of publication, country/setting, target population, and main findings related to MetS epidemiology in overweight and obese children and adolescents.Upon their inclusion, the systematic reviews underwent a snowballing process that entailed utilizing the bibliographic references and citations within these reviews. This process aimed to identify additional articles that aligned with the inclusion criteria set for our review. No articles were added to our review as a result of snowballing.The quality and applicability of the studies included were independently assessed by two researchers (F.O. and F.D’A), who used the standardized “Critical Appraisal Checklist for Analytical Cross-sectional Studies” developed by the Joanna Briggs Institute (JBI) . This toResults were summarized in narrative form and in tables and figures.The search identified 5655 records. After the removal of duplicates, 5510 articles were screened on the basis of their titles and abstracts and 476 full-text articles were selected. In adherence to the predefined inclusion and exclusion criteria, the screening process ultimately led to the inclusion of 15 articles. A comprehensive depiction of the study selection process is provided in The 15 primary studies included in our systematic review were all cross-sectional studies ,27,28,29n = 5) were conducted in Spain [n = 2) in Romania [n = 2) in Italy [n = 2) in Poland [n = 2) in Slovakia [The studies included reported pediatric MetS data regarding European countries; specifically, 34%  based their analysis on the IDF consensus for children and adolescents [The data regarding the epidemiological impact of MetS depended on the diagnostic criteria used, resulting in variations observed across different countries. More than half of the studies included  clescents , and thalescents  (6.7%) ulescents , one [21lescents , and finlescents .The main findings of this systematic review are reported below, first on analyzing the epidemiological burden of MetS among European children and youths, and then the burden of metabolic components in subjects with a diagnosis of MetS. In Europe, the epidemiology of MetS varies widely among countries. All the studies included in our review reported epidemiological data in terms of prevalence, except for one, which calculated the MetS incidence in children and adolescents . Accordin = 5, 33.3%) [n = 24). In a sample of 976 children and adolescents aged 10–15 years enrolled by González-Jiménez et al. [Spanish studies were the most numerous among those included  ,27,28,29, 33.3%)  and 19.6, 33.3%)  studied To compare the results yielded when adopting two different definitions of MetS, Galera-Martínez et al.  conducten = 35) of whom were severely obese. Although impaired metabolic components were present in 72–100% of the children enrolled, only 67 of them (55.8%) met the criteria for MetS .In Romania, Pelin et al.  investigAnother Romanian study, conducted by Stroescu et al. , analyzen = 41) aged 5–18 years, in whom the prevalence rates of overweight and obesity were 25.7% (n = 18) and 74.3% (n = 52), respectively. The diagnostic criteria for MetS were met by 14 children (20.0%), more frequently in the 11–16 age group , followed by the 16–18 age group . In contrast, in the 5–10 age group, MetS was diagnosed in only one child (7.1%).In Poland, the prevalence of MetS was reported to range between 12.9% and 20.0% ,18. The n = 38) had MetS [The MetS prevalence in Italy was reported in two of the studies included ,24. Marthad MetS .n = 80) of subjects, with a higher prevalence (44%) in those aged less than 10 years than in the 16–20 age group (18.9%) and the 10–16 age group (11.4%).The other Italian study, which adopted the IDF criteria, focused instead on the distribution of MetS and its components according to age-class in a total sample of 413 obese children and adolescents . Overalln = 38) of adolescents, with a higher prevalence among boys  than among girls . Focusing on the overweight/obesity group (n = 696) enrolled in the study, the authors estimated a MetS prevalence of 5.5%, which was higher in boys than in girls (8.6% vs. 1.8%). In another study conducted in Slovakia, during the 10-year period from 2003 to 2012, the observed overall prevalence of MetS was 2.75% among 1294 children aged under 18 years  [In Slovakia, Jurkovičová et al.  analyzedf males) .The last two studies included in this systematic review involved obese pediatric populations from Lithuania and the Czech Republic ,20.n = 73, 21.3%). The gender distribution of MetS displayed a higher prevalence in obese/overweight boys than in obese/overweight girls. Moreover, the MetS prevalence was significantly higher in obese girls than in overweight girls .In Lithuania, Smetanina et al.  studied n = 102) in the whole sample.Finally, the study by Pastucha et al.  was the Six studies included in our review  investigated the distribution of metabolic components of MetS in children and adolescents ,18,22,28n = 13) and an increase in TG concentrations , in addition to abdominal obesity in 100% of cases. Furthermore, arterial hypertension was found in 71.4% (n = 10) of MetS children, while an increase in serum glucose was detected in only one child (7.1%). Similarly, Jankowska et al. [n = 76, 100%) and increased TG levels in more than half (55.3%). Elevated blood pressure was also detected in 73% of children diagnosed with MetS. Pelin et al. [In a group of 14 children with MetS, Szabelska-Zakrzewska et al.  frequenta et al.  registern et al.  also empn = 8, 34.8%) and low levels of HDL-C , a higher prevalence was found in males.In Spain, González-Jiménez et al.  observedn = 33) had increased TG levels, and 65.7% (n = 48) had decreased HDL-C. Furthermore, elevated systolic or diastolic blood pressure was observed in 60.0% and 41.4% of these subjects, respectively.On analyzing the components of MetS in Lithuania, Smetanina et al.  found thFinally, in the Italian study by Martino et al. , 38 chiln = 8) of the studies clarified the statistical analyses employed.In order to objectively evaluate the 15 studies, we used the JBI critical appraisal checklist, and the results are presented in This systematic review provided a comprehensive overview of the epidemiological burden of MetS in overweight and obese European children and adolescents, while also comparing values obtained through different adopted definitions.According to the data analyzed, MetS epidemiology varied widely among European countries, and was reported mainly in terms of disease prevalence. Indeed, only one study reported the MetS incidence in European children and adolescents . From thIn Poland, the MetS prevalence, when calculated according to the IDF criteria, ranged from 12.9% in children aged 10–12 years to 20.0% in children/adolescents aged 5–18 years ,18.In Italy, the MetS prevalence ranged from 13% in children/adolescents aged 6–14 years, according to the Martino criteria .In Slovakia, the MetS prevalence according to the IDF criteria ranged from 2.75% in children under 18 years of age  to 5.5% Of the studies included in our review, only one, conducted in the Czech Republic, reported incidence data . In a grAlthough the data on the prevalence of MetS in the overweight and obese pediatric populations varied among the different countries considered, the different age groups, and, above all, the diagnostic criteria used, the most worrying fact is that this syndrome is frequent in European obese children/adolescents. Obesity, and in particular severe obesity, constitutes a significant public health concern, impacting a substantial number of children across Europe . A recenCountries within the Mediterranean basin have reported the highest rates of overweight and obesity, ranging from 24% to 37% . In contExtrapolating the prevalence estimates based on the WHO definition  to encomHowever, in recent decades, the growing prevalence of obesity among children and adolescents, as well as adults, has evolved into a substantial health challenge worldwide.In 2020, it was estimated that within the WHO European Region, approximately 4.4 million children under the age of 5 were impacted by overweight, including obesity, with significant disparities among different countries .The prevalence of pediatric obesity, in particular, rose dramatically from 4% in 1975 to 18% in 2016, with an increase from 5 million to 50 million girls and from 6 million to 74 million boys ,37. An aIn Africa, for instance, the count of overweight children under the age of 5 has surged by nearly 24% since 2000, and almost half of the children under 5 who were overweight or obese in 2019 lived in Asia ,42.Indeed, despite the heterogeneous patterns observed at national levels, the rising obesity prevalence represents one of the most pressing public health concerns of our era, affecting nations worldwide .2 reported an almost two-fold increase in the risk of death in adulthood compared to individuals with a BMI < 25 kg/m2 [According to several studies, 80% of adolescents aged 10 to 14 years, 25% of children younger than the age of 5 years, and 50% of children aged 6–9 years with obesity are at risk of developing obesity that persists into adulthood ,43. Furt25 kg/m2 ,44. Thus25 kg/m2 . This seSimilarly, within the studies we examined, MetS was most commonly observed among obese adolescents, displaying a prevalence of 32.1%, in contrast to a lower prevalence of 7.1% in overweight adolescents . In 2020Only six of the included studies in this systematic review concerned the prevalence of distinct components of MetS. Four out of the six reported that dyslipidemia and hypertension were the most frequent anomalies in overweight and obese children from Poland ,18, RomaAll these components could hold prognostic significance for the development of MetS, and their early detection might facilitate preventive measures, reducing its prevalence and related consequences . HoweverMoreover, the development of these criteria should take into account additional variables such as age, gender, pubertal stage, and ethnicity , encompaSimilarly, established cut-off values for lipid profiles, blood pressure, and fasting glucose levels in adults may not always be directly applicable to adolescents without considering factors such as pubertal stage, gender, ethnicity, and clinically relevant conditions . TherefoTo date, the most effective strategy to mitigate the future prevalence of MetS is to proactively prevent obesity among children and adolescents. Additionally, early detection of MetS could empower pediatricians to promptly recognize and manage children who are at a heightened risk of cardio-metabolic complications. This proactive approach could consequently contribute to the reduction of CVD and T2DM incidence in adulthood .Due to its far-reaching consequences on health, social welfare, and economic systems, addressing MetS necessitates a comprehensive array of strategies. These encompass early prevention efforts targeting overweight and obesity, as well as targeted interventions for those requiring treatment. In this regard, it is essential to promote a healthy and active lifestyle starting early in life. This involves not only sustaining adequate levels of physical activity among younger children , but alsImplementation of the Mediterranean diet, which involves consuming plenty of vegetables and olive oil, is also important. For example, in a 16-week study of adherence to the Mediterranean diet among children and adolescents, the MetS prevalence decreased (from 16% to 5%) among those on the diet, while it did not change, or even worsened, in the control group .The most impactful strategies are likely those that integrate both reducing calorie consumption and boosting energy expenditure. Additionally, there should be heightened endeavors to combat obesity and MetS through a public policy lens, which involves creating secure spaces for physical activity and advocating for nutritious options within the school setting .Our review provides evidence on the epidemiological burden of MetS in European children and youths and underlines the main risk factors, such as overweight and obesity, associated with the syndrome in this target population. It also indicates that clinicians should identify at-risk patients and provide guidance on the prevention and management of this disease. Comprehensive information on the prevalence of MetS can, therefore, support value-based decision-making aimed at identifying adequate strategies for the prevention of this disorder, which, if not managed, can lead to serious complications in adulthood.Through a comprehensive search strategy, this review has provided significant insights into the prevalence of MetS among children and adolescents in Europe.Knowing the epidemiological impact of MetS in this young population, especially concerning the complications associated with this condition and its evolution in adulthood, is essential for identifying adequate preventive strategies and improving the clinical management of children affected by obesity.Furthermore, the identification of primary risk factors associated with the syndrome, particularly the strong connections to overweight and obesity, not only enhances the comprehension of this condition but also constitutes a crucial step in formulating tailored approaches and initiatives aimed at mitigating its consequences. Notably, our results could support informed decision-making processes in public health planning and intervention efforts, thus ensuring the protection of the health and well-being of the younger generation. At the same time, by highlighting the gaps in existing research, our study underscores the need for further investigation in specific areas, such as the identification of optimal diagnostic criteria for children and adolescents and the exploration of MetS’s implications across different demographic groups.However, several limitations should be considered when interpreting our findings. Only articles published in English were included, which might have prevented us from identifying all the available evidence on the topic. While we rigorously adhered to the PRISMA statement during the screening process, it is important to acknowledge that a potential for selection bias remains, albeit not entirely eliminated . MoreoveNevertheless, our overview pinpointed several meaningful aspects, which can help in the appraisal of preventive interventions targeted to overweight and obese children and adolescents at risk of MetS.Obesity is a major risk factor for MetS development and the consequent onset of cardiovascular complications and diabetes. Although multidisciplinary lifestyle intervention has proved most efficacious , investmAnother challenge is how to intervene at the public health level in order to reduce the high prevalence of obesity in the general population. There is widespread consensus within the scientific community that combating the obesity epidemic requires a shift away from individual behavior-focused prevention and towards strategies that are rooted in the environment or community. This approach would offer the greatest possibility of reducing MetS, making the role of the pediatrician crucial to both the diagnosis and prevention/treatment of obesity and all its associated risks and/or complications.


BSCL2 gene (p.Thr109Asnfs* 5). Ultrasound revealed a hypoechoic solid nodule measuring 1.8 × 1.0 × 1.0 cm, and fine needle aspiration biopsy suggested malignancy. Total thyroidectomy was performed, and a histopathological examination confirmed PTC with vascular invasion and parathyroid lymph node metastasis (pT3N1Mx stage). This is the first report to describe a case of differentiated TC in a child with CGL. Severe insulin resistance that is generally observed in patients with CGL early in life, especially in those with type 2 CGL, may be associated with this uncommon presentation of aggressive PTC during childhood.Thyroid carcinoma (TC) is rare in children, particularly in those aged < 10 years. Several studies have demonstrated a correlation between neoplasms and hyperinsulinemia and insulin resistance, which are often associated with a higher risk for and/or aggressiveness of the neoplasm. Congenital generalized lipodystrophy (CGL) with autosomal recessive inheritance is a rare disease and is characterized by the lack of adipose tissue, severe insulin resistance, and early metabolic disturbances. Here, we reported a rare case of a type 2 CGL in a girl who presented with a papillary TC (PTC) at the age of 7 years. She had no family history of TC or previous exposure to ionizing radiation. She had a generalized lack of subcutaneous fat, including the palmar and plantar regions, muscle hypertrophy, intense acanthosis nigricans, hepatomegaly, hypertriglyceridemia, severe insulin resistance, and hypoleptinemia. A genetic analysis revealed a mutation in the  Thyroid carcinoma (TC) is rare in children, particularly those aged < 10 years, and accounts for 1.5%–3% of all childhood cancers in North America and Europe; however, its incidence has been increasing by 1.1% each year . The behSeveral studies have revealed the correlation between neoplasms and hyperinsulinemia and insulin resistance (IR), which are frequently associated with a higher risk for and/or aggressiveness of the neoplasm –6. HowevCGL is a rare disease with autosomal recessive inheritance characterized by a lack of adipose tissue, hypoleptinemia, severe IR, and early metabolic disturbances such as dyslipidemia and diabetes mellitus ,10.Here, we report a rare case of type 2 CGL in a girl who presented with PTC at the age of 7 years and who had no family history of TC or previous exposure to ionizing radiation.A 9-year-old girl with a clinical and molecular diagnosis of CGL was being followed at our center, . Based on the generalized absence of adipose tissue, she was clinically diagnosed as having CGL in her first year of life.2. She had a generalized lack of subcutaneous fat, including in the palmar and plantar regions, muscle hypertrophy, intense acanthosis nigricans, and hepatomegaly  of 20.5 kg/mtomegaly . The pattomegaly .BSCL2 gene mutation (p.Thr109Asnfs* 5), characterizing type 2 CGL.In her first year of life, hypertriglyceridemia (442 mg/dL) was detected. During follow-up, her clinical and laboratory work-up revealed IR . At 7 yeAt 7 years of age, thyroid gland ultrasound revealed a hypoechoic solid nodule measuring 1.8 × 1.0 × 1.0 cm in size, with partially defined margins and multiple foci of microcalcification located in the upper third of the right lobe. According to the clinical history, the patient had no family history of TC or previous exposure to ionizing radiation.Results of a cytological evaluation of the nodule, obtained through fine-needle aspiration biopsy, suggested malignancy (Bethesda V classification). Thus, total thyroidectomy was performed. Results of a histopathological examination confirmed a classical variant of PTC, with the tumor measuring 1.2 cm  and having vascular invasion. Perineural infiltration was not performed. Extrathyroid extension and metastasis were observed in a parathyroid lymph node (pT3N1Mx stage) . The patThis is the first study to report about a differentiated TC (DTC) in a child with CGL. Although the patient did not present with other risk factors for TC, i.e., previous radiation exposure or a family history of TC, she had severe CGL-associated IR since early childhood. Furthermore, she had an aggressive presentation of PTC (pT3N1Mx stage).AGPAT2 and BSL2 genes, respectively, which express proteins that are critical in triglyceride and phospholipid biosynthesis, lipid droplet formation, and adipocyte differentiation  are overexposed in most DTC cases ,22. In aIGF-1 plays a role in various human malignancies and possibly in DTC ,22. IGF-Some studies have described the presence of high leptin levels in patients with DTC . Cheng aAlthough our patient had no clinical diagnosis of diabetes, she had altered glycated hemoglobin levels. Most studies have demonstrated the correlation between diabetes and DTC. In their case-control study, Bae and cols. observed that Korean women in the upper quarters of HOMA-IR had an odds ratio of 4.07  for DTC. These data were adjusted for age, BMI, history of smoking, hypertension, thyroid disease, other cancers, cholesterol levels and TSH .In the meta-analysis conducted by Yeo and cols., women with pre-existing DM had an increased risk for TC  . A similHowever, it is unlikely that the association reported here is a random occurrence. The occurrence of DTC in children aged < 10 years is rare and is usually associated with the presence of identifiable risk factors such as a family history and exposure to ionizing radiation during childhood; however, this was not observed in our patient. Our patient had IR since her first year of life, which was related to the most severe subtype of CGL. Our case findings reinforce the hypothesis that IR is a trigger for CGL, independent of BMI or leptin levels.In conclusion, this is the first report to describe DTC in a child with CGL. The severe IR usually observed in this disorder early in life, especially type 2 of CGL, may be associated with the uncommon presentation of aggressive PTC during childhood. Future prospective studies are needed to better define the association between TC and severe IR and demonstrate the possible benefit of thyroid evaluation in patients with CGL.


Mitochondrial DNA (mtDNA) is an effective genetic marker in forensic practice, especially for aged bones and hair shafts. Detection of the whole mitochondrial genome (mtGenome) using traditional Sanger-type sequencing is laborious and time-consuming. Additionally, its ability to distinguish point heteroplasmy (PHP) and length heteroplasmy (LHP) is limited. The application of massively parallel sequencing in mtDNA detection helps researchers to study the mtGenome in-depth. The ForenSeq mtDNA Whole Genome Kit, which contains a total of 245 short amplicons, is one of the multiplex library preparation kits for the mtGenome. We used this system to detect the mtGenome in the blood samples and hair shafts of thirty-three individuals from eight two-generation pedigrees, one three-generation pedigree, and one four-generation pedigree. High-quality sequencing results were obtained. Ten unique mtGenome haplotypes were observed in the mothers from the ten pedigrees. A total of 26 PHPs were observed using the interpretation threshold of 6%. Eleven types of LHPs in six regions were evaluated in detail. When considering homoplasmic variants only, consistent mtGenome haplotypes were observed between the twice-sequenced libraries and between the blood and hair shafts from the same individual and among maternal relatives in the pedigrees. Four inherited PHPs were observed, and the remainder were de novo/disappearing PHPs in the pedigrees. Our results demonstrate the effective capability of the ForenSeq mtDNA Whole Genome Kit to generate the complete mtGenome in blood and hair shafts, as well as the complexity of mtDNA haplotype comparisons between different types of maternal relatives when heteroplasmy is considered. Circular double-stranded mitochondrial DNA (mtDNA) has been commonly detected in forensic cases where the samples are aged or lack nuclear DNA  ,2. It isAt present, massively parallel sequencing (MPS), whereby a large number of markers and samples can be detected in one sequencing run ,14, provBoth long-amplicon multiplexes  ,35,36 anThe present study aimed to evaluate the performance of the ForenSeq mtGenome Kit in the detection of the mtGenome in blood samples and hair shafts, the ability of this panel to distinguish heteroplasmy, and the characteristics of variant transmission and variant difference between maternal relatives. Thus, we used this well-validated  multipleAll samples were anonymously collected from Guangdong Han Chinese people with informed consent. This study was approved by the Ethics Committee of Zhongshan School of Medicine, Sun Yat-sen University (No. [2020]044).Both peripheral blood samples and hair shaft samples were collected from 11 individuals in a 4-generation pedigree, and peripheral blood samples were collected from 6 individuals in a 3-generation pedigree and 16 individuals in 8 2-generation pedigrees  NaClO, sterilized distilled water, 10% ethanol, and 100% ethanol in turn . The firDNA libraries were constructed using the ForenSeq mtGenome Kit according to the manufacturer’s instructions . BrieflyThe raw sequencing data were first analyzed using ForenSeq UAS v2.1 . The seqhttps://blast.ncbi.nlm.nih.gov/, accessed on 20 December 2022). For variant calling, the Verogen mtDNA whole-genome analysis method (default thresholds) [The NUMTs and byproducts were removed automatically using UAS v2.1, and the sequence strings with mixed bases were screened with BLAST tools (esholds)  was usedThe variants called using UAS v2.1 were checked using the ‘Alignment’ function on the EMPOP website , whereinThe variant transmission was evaluated between mother and offspring pairs, and the variant differences were evaluated between individuals from all maternal relatives. To classify the transmission of heteroplasmy between relatives, the types of heteroplasmy were defined as follows: inherited heteroplasmy was heteroplasmy that was observed in both the mother and her offspring; de novo heteroplasmy was heteroplasmy that was observed only in the offspring and absent in the mother; disappearing heteroplasmy was heteroplasmy that was only observed in the mother and was absent in her offspring . The MAF2, and the average total read depth was 562,592 ± 331,109×, for all sequenced libraries  were sequenced in this study, in which 16 libraries were sequenced twice. The average cluster density was 1560.6 ± 228.32 k/mmibraries . The aveIn the results of the 60 sample libraries, only 1.68% of all the positions had a strand bias value over 0.6 . Most ofA total of 34 variants were observed in HL60 using the default analysis thresholds, with an average read depth of 4107.34 ± 3378.87×. Among the observed variants, 33 were SNPs, and one was an insertion (315.1C). No base call was observed at np 6734. The haplogroup of HL60 used was assigned as J2b1a1a via ‘Haplogrouping’ tool. As for the negative control, no base call or variants were called in NC-AMP and NC-EXB using the default thresholds, while 22 variants were called in NC-EXH, with an average read depth of 627.68 ± 464.62×. The average RRDs of NC-AMP and HL60, NC-EXB and HL60, and NC-EXH and HL60 were 0.07%, 0.03%, and 5.40%, respectively .Among the 16 twice-sequenced libraries, both the total read depth and mtGenome coverage in the second sequencing run were higher than those in the corresponding libraries in the first sequencing run, except for P15-H and P14-B . The paiAs for the 11 hair shafts and the corresponding blood samples from the same individuals, the total read depth did not show a significant tendency towards either of the tissues , and theIn the blood samples from 33 individuals, a total of 1247 variants were observed at 172 nucleotide positions, and 178 types of variants were included. Of the 178 types of variants, 167 were SNPs, 8 were insertions, and 3 were deletions . A totalTen different mtDNA haplotypes were observed in the mothers from ten pedigrees in the control region, coding region, and whole mtGenome. Inside the coding region, different haplotypes were observed in 17 gene-coding regions, while the remaining 20 regions showed the same haplotypes. The top three haplotype types were observed in NADH dehydrogenase 5 (ND5), ATP synthase 6 (ATP6), and CYB, with nine, eight, and eight haplotypes, respectively .The tri-alleles T9824A/C and C13683A/G were observed in this study, wherein variant call A was observed in four samples and variant call C was observed in two samples at np 9824, and variant calls A and G were observed in two samples, separately, at np13683. A total of 10 unique haplogroups were assigned in the 10 pedigrees, of which 5 were nested in super haplogroup M and 5 were nested in super haplogroup N. The assigned haplogroups were the same among the family members from the same maternal pedigrees .Among the 33 blood samples, 12 (36.36%) samples were observed to have 1~2 PHPs  in both the blood samples and the hair shafts. In the 11 pairs of same-origin blood samples and hair shafts, no overlapping PHPs were observed in any tissue pairs.Length variations that were different from the rCRS were observed at nps 303–315, 955–966, 12,417–12,426, 16,180–16,194, 249, 514–524, and 8271–8279. Sequence variations in the first four regions were caused by base insertions of C or A , while variations in the last three regions were due to base or fragment deletions. Excepting np 249 (249DEL), LHPs were observed in all the regions described above .To locate the accurate position of the poly-C or poly-A stretches, we took the non-repetitive bases at both ends of a fragment as the anchor position to grab the target fragment and used an abbreviated form to show the variant. For example, variant type ‘A-7C-T-6C-G’ represents sequence ‘ACCCCCCCTCCCCCCG’ from nps 302 to 316, wherein the consecutive Cs are interrupted by 310T, and compared with the rCRS, the variant of this fragment is 315.1C. The 315.1C variant was observed in all 44 samples, except for 1 sample that presented no base call in this region. Additionally, more than 7 Cs were observed at nps 303–309 in 35 samples. No transition of T > C was observed at np 310. LHP was observed when eight consecutive Cs existed. As shown in The T961C variant led to a sequence with more than 10 consecutive Cs at nps 955–966. A total of 20 samples showed a sequence with 12 consecutive Cs varying in length, and 4 samples were observed to have a sequence with 13 consecutive Cs. Additionally, it is worth mentioning that the read count dropped precipitously at np 964, whose average read count was only 21.97% ± 5.23% of that at np 963. Similarly, the length variation at nps 16,180–16,194 was caused by T16189C, and the T > C transition at nps 16,182 and 16,183 exacerbated the C-stretches. As the only polyadenine stretch, LHP happened when nine consecutive As occurred at np 12425. Mixed variation in 523A, 524C, and 523–524DEL (with an average frequency of 84.52% ± 0.98%) was observed at nps 523–524. A similar situation was also observed for the 9bp deletion fragment at nps 8272–8280 . The aveA total of 53 comparisons were carried out for the 23 mother–offspring pairs , in whicWhen heteroplasmic variants were considered, 42 comparisons showed different haplotypes . The difInherited PHPs were observed in Family1 (152Y), Family8 (3386Y), P08-P15 (9083Y), and P12-P18 (14215Y); conversely, de novo and disappearing PHPs were the majority . The paiA total of six groups of immediate three-generational family members  and one group of immediate four-generational family members  were included in this study. PHPs were observed in both the blood samples and hair shafts in the four-generational group and two three-generational groups and were also observed in the hair shafts of one three-generational group . The traBesides the mother–offspring pairs, comparisons were also carried out in 10 other types of maternal relationships . SimilarIn this study, we used a fire-new mtDNA Whole Genome Kit that was designed with small amplicons (averaging at 131 bp) ,42 to seIn this study, the quantity of the input DNA and the processes before library pooling followed the manufacturer’s instructions completely. When using the recommended number of pooling libraries (16 libraries) and the recommended volume of pooled libraries (5 μL) that was added to the Miseq sequencing reagent cartridge, 73.33% of the sequenced libraries  showed a total read depth of lower than 300,000×. To maximize the data coverage and quality, we lowered the number of pooling libraries to 12 and increased the volume of pooled libraries to 5.3 μL in the later sequencing runs. These adjustments proved to be effective at increasing the total read depth and mtGenome coverage throughout the results of run 1, run 4, and run 5 . Thus, rThis kit performed well in terms of the sequence strand balance. The percentage of positions with strand bias 1.68%) was lower than that in samples sequenced using the Ion Torrent PGM platform (10%) , the Ion.68% was Completely consistent homoplasmic variants were observed in the HL60 samples in our study, previous studies ,54, and Due to the high sensitivity of the mtGenome multiplex and the unavoidable inclusion of aerosol during the pipetting process, sporadic base calls were unavoidable in the negative controls. When the default variant calling thresholds were used, no variant call was observed in NC-EXB and NC-AMP, which indicates ignorable contamination during the DNA extraction process of the blood samples and the library construction and sequencing process. On the contrary, remarkable variants were present in the negative control of the hair shaft extraction (NC-EXH). Among the 22 observed variants, 8 overlapped with HL60 and P01-H. When compared with all the samples in this study, there were still nine variants that were not traced. Additionally, these variants were not recorded in the EMPOP database , and manThe distribution of variants in the mtGenome in this study was similar to that in the North Han Chinese population reported by Zhou et al.  and in tHowever, no overlapping PHPs have been observed in previous studies ,10,23,52Extreme strand bias was only observed at nps 303–315 and np 16193.1 in the 16,180–16,194 fragment. 310T interrupted the C-stretches at nps 303–315, which resulted in nine consecutive Cs in this region. Variant 309.1c was called when both the read depth and frequency of reads with the insertion of C and reads without the insertion of C (reference reads) reached the thresholds; otherwise, variant 309.1C was called. A relatively high frequency occurred when the total read depth was low, even with a read count that was less than 45 reads ; nonetheless, a homoplasmic variant was called. A similar situation existed in the np 955–966 and np 16,180–16,194 fragments. An N-1 stutter in np 16,189 was observed, and the count of stutter reads was 13.74% of that of the parental allele. This is similar to the mechanism that results in stutter products associated with the detection of short tandem repeat (STR) markers . AlthougThough the sequencing-by-synthesis mechanism of the Illumina sequencing platform can reduce the risk of sequencing error in the polymeric region, the lower thresholds of variant calls  may increase the complexity of variants in regions with length variations. Thus, we recommend that caution be taken when classifying LHP calls and that the minimum variant frequency of length variation should be raised . AddThe variant transmission of the mtGenome between the maternal family members in this study still followed maternal heredity. Meanwhile, we also observed differences that were mainly caused by heteroplasmic variants. These variants are de novo or disappearing variants in the lineage. The transmission of inherited heteroplasmic variants can improve the weight of evidence when evaluating individuals from the same maternal lineage, while different heteroplasmies may have the potential to distinguish individuals from the same maternal ancestry, especially when the heteroplasmic variants are only shared in tissues of the particular individual .In this study, the six groups of immediate three-generational family members and the group of immediate four-generational family members were from only two maternal lineages; thus, limited information on the characteristics of PHP transmission was found. PHP that was transmitted from the grandmother to the third- or fourth-generation member was not observed. Meanwhile, in the observed inherited PHPs, the direction and magnitude of the frequency change during transmission were moderate and seemed to be random, and this is consistent with Liu et al.’s research on sixteen four-generation pedigrees . Zaidi eIn this study, though only four inherited PHPs were observed, the length variations were inherited in most of the maternal relatives, which can also improve the matching probability of the same maternal origin among the relatives. Optimizing the thresholds for LHP variant calling or using a major molecule comparison helps to decrease the complexity of a variant mixture and can support the same maternal origin relationship further. Meanwhile, more pedigree studies are needed to further confirm the observation that more variant differences existed between the relatives of third-degree relationships. As for the mtGenome haplotype comparisons between maternal relatives, the revised guidelines by the ISFG recommends that differences in both PHPs and LHPs do not constitute evidence for excluding two identical haplotypes deriving from the same source or the same maternal lineage . HoweverIn recent years, some mtDNA detection panels have been established for forensic use based on MPS platforms. In this study, we used a new mtGenome detection panel, the ForenSeq mtGenome Kit, to detect blood samples and hair shafts from maternal-pedigree individuals. Firstly, we demonstrated the effectiveness of this panel in blood and hair shaft detection through the deep read depth and complete mtGenome coverage. Secondly, the ForenSeq mtGenome Kit plus ForenSeq UAS v2.1 software can distinguish between PHPs and LHPs clearly, while the threshold setting function for LHP needs to be improved. Thirdly, we observed a stable transmission of homoplasmic variants among maternal pedigrees and variable differences in heteroplasmic variants between maternal relatives. Random MAF changes among three/four-generation pedigrees were also observed. Lastly, we proved that a high risk of false exclusion will present itself if the differences in both PHPs and LHPs are included for exclusion. In the future, hair shafts from different body parts and various types of tissues, especially challenge materials, should be investigated to obtain more comprehensive knowledge of the mtGenome.