Clozapine is considered the gold standard for patients with treatment-resistant schizophrenia (TRS) who have previously tried other antipsychotics at adequate doses . However, despite optimal treatment, a subgroup of TRS patients with what is known as ultra-treatment-resistant schizophrenia (UTRS) fails to respond to clozapine, which occurs in 40–70% of cases. The most common approach to manage UTRS involves augmenting clozapine with pharmacological or non-pharmacological interventions, with a growing body of evidence that supports the use of electroconvulsive therapy (ECT) as an augmenter. This prospective non-randomized 8-week study, which followed the TRIPP Working Group guidelines and is one of few that separate TRS from UTRS, aimed to evaluate the effectiveness of clozapine in TRS patients and the efficacy of ECT augmentation of clozapine in UTRS patients. Patients with TRS were assigned to receive clozapine alone (clozapine group), whereas UTRS patients received bilateral ECT in addition to their current medication regimen (ECT plus clozapine group). The severity of symptoms was evaluated using the Clinical Global Impression Scale (CGI) and Positive and Negative Syndrome Scale (PANSS) at baseline and at the end of the 8-week trial. Both treatment approaches resulted in improved CGI and PANSS scores. The results suggest that both clozapine and ECT are effective treatment options for patients with TRS and UTRS, respectively, and that adherence to guidelines should provide a better frame for future clinical studies. Treatment-resistant schizophrenia (TRS) is a major cause of disability, affecting up to 34% of those diagnosed with schizophrenia . The staDespite some contrary opinions based on a network meta-analysis conducted by Samara et al. in 2016, clozapine is still considered the preferred treatment option for patients diagnosed with TRS ,8,9. Devn = 42) of the combination of clozapine and ECT in CRS, assigning CGI scores based on medical documentation, and reported a positive response rate of 76%, with 75% of responders not requiring hospitalization over the course of one year [n = 7) and the study lacked the use of CGI scores, it demonstrated promising results. In a high-quality study of individuals with clozapine-resistant symptoms, ECT augmentation resulted in 50% of participants achieving a response compared to 0% of participants who received clozapine without ECT augmentation; the sample included 39 participants  [n = 1769), conducted by Wang et al., concluded that ECT augmentation of clozapine in CRS is highly effective and relatively safe [The management of UTRS remains a challenge in the field of psychiatry. The most common approach to address this condition is through augmentation with other medications, such as additional antipsychotics, anxiolytics, mood stabilizers, and antidepressants. However, despite these efforts, there is limited evidence to support the efficacy of augmentation with other medications ,17,18,19one year . Anotherone year ; althoug n = 20) . A meta-ely safe .Overall, the available data implies that adjunctive non-pharmacological therapies such as ECT may prove to be beneficial in individuals with TRS/UTRS. Based on these data, we conducted a prospective non-randomized study to evaluate the effectiveness of clozapine in TRS patients and the efficacy of ECT augmentation of clozapine in UTRS patients. The goal was to see how two different groups of patients, previously differentiated by the TRIPP criteria, would respond to therapy. This study is one of the few that adheres to the TRIPP Working Group guidelines and distinguishes TRS from UTRS. Failure to differentiate between these two conditions can pose a significant challenge in defining the neurobiology of the disease. It seems reasonable to subtype based on treatment response, and studying the mechanisms leading to TRS and UTRS, as well as their differences, could offer an opportunity to develop novel treatments.This was a non-randomized prospective study incorporating non-blinded treatment and blinded assessments. It included patients with treatment-resistant and ultra-treatment-resistant schizophrenia (TRS and UTRS) that were assigned to two treatment groups. Patients with TRS were introduced to clozapine (clozapine group) for 8 weeks, whereas the others received a course of bilateral ECT in addition to their current pharmacotherapy regimen (ECT plus clozapine group), also during an 8-week period.All participants were recruited from the inpatient units of the University Hospital Center Sestre Milosrdnice in Zagreb, Croatia, between September 2020 and August 2022. The Ethics Committee of the University Hospital Center approved the study. All patients that fulfilled TRS and UTRS criteria were eligible for being part of this study. Accordingly, all the consecutive patients diagnosed with TRS and UTRS were approached upon hospitalization. After a complete and extensive description of the study profile, only subjects with signed informed consent forms were included. The forms were signed either by subjects themselves or by their legal tutor.Patients of both sexes, aged between 18 and 65, were included. All of them fulfilled criteria for a DSM-5-TR diagnosis of schizophrenia based on a clinical interview and follow-up of experienced psychiatrists from the Sestre Milosrdnice University Hospital Center. Additionally, they also fulfilled TRRIP criteria for either TRS or UTRS. All subjects or a legal tutors signed an informed consent form.Treatment-resistant schizophrenia (TRS) was defined according to TRIPP criteria:(1) Determination of treatment non-response. Defined as <20% symptom reduction over ≥6 weeks. For evaluation, we used the Clinical Global Impression Scale (CGI) and the Positive and Negative Syndrome Scale (PANSS) ,29.(2) Determination of treatment resistance. Defined as non-response to ≥2 adequate treatment trials. In our study, each subject has had a history of at least two failed trials of ≥600 mg of chlorpromazine equivalents for at least 6 weeks.(3) Determination of adequate treatment trial. Defined as at least a 6-week trial at a therapeutic dose equivalent to ≥600 mg chlorpromazine daily.(4) Determination of adherence. Defined as ≥80% prescribed doses taken. In our study, this was assessed with the following methods: pill counts and dispensing chart reviews. Obtaining an antipsychotic blood level at least once is also requested, which was performed without advanced warning.Ultra-treatment-resistant schizophrenia (UTRS) meets all of the criteria above, with the addition of non-response to adequate trial on clozapine. After plasma levels reach 350 ng/mL, a trial should last at least 3 months. Our subjects with UTRS fulfilled all of the suggested criteria.Individuals with a history of epilepsy, ECT treatment within 6 months prior to enrollment in the study, severe neurological or systemic disorders that could significantly impact cognition, behavior or mental status (excluding tardive dyskinesia or neuroleptic-induced parkinsonism) within 3 months prior to the study, and psychoactive substance abuse (excluding nicotine or caffeine) within 1 month prior to the study were excluded from participation.Participants in both groups were on clozapine either in monotherapy or in combination with other psychotropic drugs. Concurrent use of other antipsychotic, antidepressants, or anticonvulsants was allowed as long as they were taken at a stable dose for at least 12 weeks before entering the study. Both groups were similar in terms of the types of drugs used, the main difference between them was that patients in the clozapine group were newly initiated on clozapine, whereas those in the ECT plus clozapine group had previously received clozapine.In the clozapine group, patients were allowed, based on the decision of their treating physician, to remain on their previous psychopharmacological medications, primarily antipsychotics, if they had a different mechanism of action than clozapine. Seven patients were using risperidone, five were using aripiprazole, three were using haloperidol, and one was using cariprazine in this group. Four patients in this group were also using valproate, but none of them were taking a combination of two antipsychotics and valproate.In the ECT plus clozapine group, all patients had previously been treated with clozapine and continued to use it during the study. Of the 36 participants, 6 were using a combination of clozapine and risperidone, 5 were using a combination of clozapine and haloperidol, 5 were using a combination of clozapine and aripiprazole, and 3 were using a combination of clozapine and cariprazine. In terms of other medications, three patients were taking low doses of escitalopram.The Thymatron System IV  was used for bilateral ECT with a standard brief pulse stimulus threshold titration and dosing . To induEligible, consenting patients had a complete baseline medical and psychiatric evaluation. Patients were rated at baseline and after trial completion (end of week 8 for both groups). The severity of symptoms was evaluated by the CGI and PANSS ,29.Raters were blinded for a patient’s group status and received treatment.p-value = 0.05/5 = 0.01). We considered a difference to be statistically significant if the p-value was less than 0.0002. The statistical analysis was carried out using SPSS software .To assess the normal distribution of the data, we utilized the Kolmogorov–Smirnov test. We presented the demographic and clinical characteristics of the two groups as percentages, as well as mean ± standard deviation (SD). We employed a repeated measures analysis of variance (RM ANOVA) to examine the PANSS scores at baseline and at week 8, while also adjusting for confounding covariates. Between-group factors (clozapine and ECT augmentation) and within-group factors were set. Additionally, we conducted an RM ANOVA to measure CGI scores. To rule out type I errors, we employed the Bonferroni correction as we had five different variables in the same model  provided their consent to participate in the study. The clozapine group consisted of 35 patients, whereas 39 patients met the inclusion criteria for the UTRS (clozapine plus ECT group). In the clozapine group, 33 out of the 35 patients completed the 8-week clozapine phase, with two patients dropping out due to their refusal to continue participating in the study while there was no change in their treatment. In the clozapine plus ECT group, 36 out of 39 participants completed the 8-week trial, whereas three individuals dropped out early, refusing further ECT treatments.The mean age of patients in the clozapine group was 55 ± 9 years, whereas the mean numbers of episodes and hospitalizations were 4.5 ± 2 and 5 ± 5, respectively. On the other hand, the mean age of patients in the ECT augmentation group was 38.5 ± 13 years, whereas the mean numbers of episodes and hospitalizations were 8 ± 5, and 6 ± 3, respectively. The mean duration of illness was 211 ± 136 months for the clozapine group and 128 ± 108 months for the clozapine plus ECT group. Other demographic characteristics are shown in p < 0.001, partial eta squared = 0.888). However, there was no significant interaction between the type of intervention and time, indicating that both groups showed similar improvements in CGI scores over time  = 0.664, p = 0.418, partial eta squared = 0.010). After Bonferroni correction, the separate influence of the two types of interventions was not significant (F(1.68) = 0.664, p = 0.418, partial eta squared = 0.010), suggesting that both clozapine and ECT augmentation of clozapine are equally effective in improving CGI scores in TRS and UTRS patients.Statistical analysis showed a significant difference between the groups in initial Clinical Global Impression (CGI) scores  = 520.858, p < 0.001, partial eta square = 0.669). A significant interaction between time and type of intervention was observed  = 18.157, p < 0.001, partial eta squared = 0.213), with both groups showing an improvement in positive symptom subscores. The separate influence of the two types of intervention was also significant (F(1.68) = 18.157, p < 0.001, partial eta square = 0.213), indicating that clozapine and ECT augmentation of clozapine are NOT equally effective.After comparing the initial values, it was determined that there was a statistically significant difference between the groups  = 135.495, p < 0.001, partial eta square = 0.734). There was no significant interaction between the type of intervention and time  = 7.901, p = 0.006, partial eta squared = 0.105), where both groups recorded an improvement in negative symptom subscores; the separate influence of the two types of intervention was significant, F(1.68) = 7.901, p < 0.006, partial eta square = 0.105, which means that both interventions are NOT equally effective.By comparing the initial values, a statistically significant difference between the groups was determined  = 184.690, p < 0.001, partial eta square = 0.725). There was no significant interaction between the type of intervention and time  = 11.659, p = 0.001, partial eta squared = 0.148), where both groups recorded an improvement in general psychopathology subscores; the separate influence of the two types of intervention was significant, F(1.68) = 11.659, p = 0.001, partial eta square = 0.148, which means that both interventions are equally effective.A comparison of the initial values revealed a statistically significant difference between the groups  = 176.795, p < 0.001, partial eta square = 0.798). A statistically significant influence of time was determined  = 18.987, p < 0.001, partial eta squared = 0.221), where both groups recorded an improvement measured in total scores; the separate influence of the two types of intervention was significant, F(1.68) = 18.987, p < 0.001, partial eta square = 0.221, which means that both interventions are NOT equally effective.By comparing the initial values, a statistically significant difference between the groups was determined  = 264.891, No significant differences in side effects were observed between the two groups in relation to any of the rated symptoms. Additionally, there were no ECT-related side effects observed during the study. This was expected as the stimulus intensity required to exceed the seizure threshold was lower (40% max), and therefore, any potential adverse effects were minimized.Clozapine has been widely recognized as the gold standard treatment for TRS due to its superior efficacy in improving positive, negative, and cognitive symptoms, as well as reducing the risk of suicidal behavior and hospitalizations. In addition to clozapine, ECT has been increasingly recognized as an effective augmentation strategy and remains the oldest biological treatment used in modern psychiatry. The present study’s findings are consistent with previous case reports and studies that have suggested the effectiveness of both clozapine and ECT in the management of TRS and UTRS patients ,34,35,36The definitions of TRS and UTRS are outlined in guidelines but are underrepresented in clinical trials. This distinction is crucial for understanding the neurobiology of the disease, as these two forms of illness may have distinct pathological and pathophysiological characteristics. Studies that have directly compared TRS with UTRS or UTRS with healthy control individuals have shown that UTRS is associated with lower prefrontal perfusion, smaller thalamic volume, higher anterior cingulate gyrus glutamate levels, low-grade peripheral inflammation, and weaker network connectivity ,40,41,42To enhance our comprehension of TRS and UTRS, it is essential that independent studies adhere to standardized and objective criteria, listed in various guidelines. UTRS is generally defined as a lack of appropriate response to the drug with clozapine plasma levels of 350 ng/mL or above and a minimum duration of clozapine therapy of 8–12 weeks after achieving therapeutic plasma levels, according to several schizophrenia guidelines such as the TRIPP Working Group, the World Federation of Societies of Biological Psychiatry (WFSBP), and the Canadian guidelines for the Pharmacotherapy of Schizophrenia in Adults. The recommended clozapine dosage varies among guidelines, ranging from 100 to 900 mg/day. Given that the lack of consistent or absent definitions in publications has impeded the acquisition of high-quality evidence for the treatment of UTRS, adhering to guidelines is crucial for future clinical studies to have a better framework.Evaluating the baseline parameters of our subjects, we encountered a moderately ill population in the ECT augmentation group and a markedly ill one in the clozapine group see . HoweverOur study was designed with several key considerations in mind. Firstly, we focused on patient selection. By using consensus guidelines and the recommendations of the TRRIP Working Group, we ensured that our study was comparable with others and could be replicated in future studies. So far, the lack of consensus in defining or diagnosing TRS was likely an important reason why many findings have not been replicated and have conflicted with each other. Another important aspect of our study was the size of the sample. Over a period of nearly two years, we were able to obtain an acceptable sample size, with two evenly matched groups in terms of the number of participants. Additionally, we used widely accepted rating scales, such as the CGI and PANSS, to provide appropriate efficacy assessments.However, our study also has several limitations. Firstly, it was non-randomized and included only Caucasian inpatients. Future studies could benefit from using a randomized design and a sample that includes participants from other ethnicities. Secondly, we did not conduct statistical analysis of the demographic differences between groups. Instead, we treated them as two distinct cohorts with two distinct forms of illness. Thirdly, almost all of our patients were prescribed additional psychotropic medications in addition to clozapine. This may have confounded our results, making it difficult to determine the specific effects of clozapine and ECT augmentation therapy. Lastly, our study only followed patients for a short period of time, which prevented us from drawing conclusions about the long-term effects of clozapine and ECT augmentation therapy in this sample.


Equisetum arvense (horsetail) powder, were added in varying amounts to achieve the desired properties. The mechanical properties of the resulting green composites, including impact and compressive strength, as well as maximum bending force value, were evaluated. The morphology and internal structure of the fractured samples were analyzed using scanning electron microscopy (SEM) and an optical microscopy. The highest impact strength was measured for the composites with beeswax, fir needles, recyclable paper, and beeswax fir resin and recyclable paper, 19.42 and 19.32 kJ/m2, respectively, while the highest compressive strength was 4 MPa for the beeswax and horsetail-based green composite. Natural-material-based composites exhibited 60% higher mechanical performance compared to similar commercial products used in the automotive industry.The first part of this paper is dedicated to obtaining 3D-printed molds using poly lactic acid (PLA) incorporating specific patterns, which have the potential to serve as the foundation for sound-absorbing panels for various industries and aviation. The molding production process was utilized to create all-natural environmentally friendly composites. These composites mainly comprise paper, beeswax, and fir resin, including automotive function as the matrices and binders. In addition, fillers, such as fir needles, rice flour, and  The circular (bioresources) economy is considered one of the most sustainable potential solutions to the global challenges of energy crises and environmental pollution. The research community has approached this issue from two main paths: recycling waste to develop novel materials and using natural resources to create new materials. One area of significant attention for researchers is the development of fiber-reinforced composite materials, which have the potential to be used in (semi) structural applications . In the Extensive studies in the specialized literature indicate that many composite materials with natural reinforcements use polymeric matrices that exhibit good or even very good physical–mechanical properties ,12. Howe2 release during when obtaining natural fiber composites is negligible as compared to synthetic fiber [Composite material development by using natural fibers promotes reductions in greenhouse gas emission, biodegradability, job availability increase, energy saving, easy decomposition, lightweight, high specific mechanical properties, less tool wear during processing, and less density, lowering the product cost. However, there are some shortcomings when using natural fiber composites due to their hydrophilic nature and the potential of moisture absorption, debonding the fillers from the matrix ,33,34,38ic fiber . The comic fiber ,37.Beeswax is derived from honey combs and is shown as a complex mixture of several chemical compounds mostly used in the food industry  . PraveenEquisetum arvense onto recyclable paper.To the best of our knowledge, there are no previous studies on the fabrication of green composites by pouring natural material blends based on beeswax, fir resin, fir needles, and Equisetum arvense. In the second stage, eco-composites were prepared through mold casting (pouring) several natural blends of beeswax, fir resin, with or without fir needle, rice, or Equisetum onto recyclable paper. This study aims to contribute to the development of sustainable materials and to reduce waste generation from paper consumption, while also exploring the potential of natural resources for composite material production.This work presents a novel approach for the development of eco-friendly composites, consisting of two stages. Firstly, specific molds were 3D-printed using PLA to mold the natural composite receipts based on recyclable paper, beeswax, fir resin, fir needles, rice, and The major advantage of these composite materials is that both the matrix and reinforcement are natural, biodegradable, and recyclable.This study is part of a larger research program aimed at assessing the feasibility of using the obtained composites for various industrial applications, such as sound insulation, thermal-insulating panels, or shock absorbers. In this particular study, we will focus specifically on the mechanical properties of the composites. By examining the mechanical properties, we can better understand how these materials can be optimized to provide the necessary insulation and damping and to gain a more specific insight into their potential application domains.Equiseti herba), rice flour, and paper pulp, offer a high degree of recyclability, low cost, and minimal environmental impact.The research employs a variety of natural materials, such as polymers, resins, waxes, and biomass waste, to produce composite materials with good sound-absorbing properties. These materials, which include beeswax, fir resin, ground fir needles, horsetail , which contribute to the strengthening and thermal stabilizing effect of wax and/or resin. Rice flour, on the other hand, contains starch, waxes, and proteins that are compatible with the chosen matrices, while milled paper (recycled cellulose) has a high specific surface area and absorbency compared to wax and resin. These unique properties of the natural materials make them excellent candidates for the development of eco-friendly composites with enhanced mechanical and thermal properties.(a)Beeswax (Ca) and ground horsetail (Cc)—a total of 14 composite materials were obtained. Percent of ground horsetail between 0 and 39.4%.(b)Beeswax (Ca) and recycled paper (Hr)—a total of 18 composite materials were obtained. Percent of recycled paper was between 0 and 46%.(c)Beeswax (Ca) and ground rice (Or)—a total of 10 composite materials were obtained. Percent of ground rice was between 0 and 86.5%.(d)Beeswax (Ca) and ground fir needles (Abr)—a total of 10 composite materials were obtained. Percent of ground fir was between 0 and 86.5%.Thus, the following eco-composites were preliminarily analyzed from the point of view of SHORE D hardness:A common/household grinding machine was used for grinding and bringing it to the desired size, and to determine the granulation size, a system equipped with mesh sieves between 0.036 mm and 0.5 mm diameter was used.For each material in powder form, the amount was gradually increased step by step with 0.25 g and then calculated as a percentage of the entire composite.Equiseti herba, rice flour, and paper pulp) were chopped to the desired granulation, weighed, and prepared according to the preset recipes for the next step, namely mixing with beeswax.First of all, all the elements  and mixed with various reinforcements (presented above) in different proportions until the reinforcer/hardener was maximally moistened.Last step was to pour the composite while it was still in a pasty state in the mold.Recyclable paper 100% denoted as S1 (as base for comparison with new composites)Beeswax (50%) + fir resin (50%) denoted as S2Beeswax (62.5%) + horsetail (37.5%) denoted as S3Beeswax (55.56%) + recycled paper (44.44%) denoted as S4Beeswax (45.5%) + milled rice (54.5%) denoted as S5Beeswax (61.5%) + milled fir needles (38.5%) denoted as S6Beeswax (31.25%) + fir resin (31.25%) + horsetail (37.5%) denoted as S7Beeswax (27.78%) + fir resin (27.78%) + recycled paper (44.44%) denoted as S8The combinations that produced the best results were identified, and we decided to use these combinations as a basis for developing new composite materials, as follows:To assess the mechanical properties of the natural composite materials, including their flexural strength, impact resistance, and compression resistance, specific molds were designed using SolidWorks 2016 software. These molds were specifically tailored to the unique characteristics of the natural composite materials under study. The molds were then created using 3D-printing technology, utilizing the Fused Filament Fabrication (FFF) technique to produce positive molds.Silicone rubber was subsequently cast into the positive molds, creating negative molds that were then used to shape the natural blends into their final form. These natural blends were poured into the negative molds, which were designed to be made from recyclable paper, enabling a sustainable and environmentally friendly production process. By utilizing this process, precise and accurate measurements of the natural composite materials’ mechanical properties were obtained, providing valuable insights into their potential applications.International Standard ISO 14125—Plastics, Subcommittee SC 13, Composites and reinforcement fibers—was the basis for testing the samples but not the only one; ISO 178 or ASTM D 790 was consulted, for example.The photo images taken from the 3D-printed molds are presented in This method of obtaining the molds for testing the mechanical properties of the samples was chosen due to the particularities of these eco-composites: precise, simple, and efficient.Equisetum arvense as the reinforcing materials. These materials were selected for their biodegradability, recyclability, and sustainable sourcing. Specifically, the fir resin and fir needles were collected during trips to coniferous forests in Brasov, Romania, from fallen branches on the ground. The natural beeswax was purchased from Apsirom SRL Vaslui, Romania, while the allimentary (grocery-grade) rice and Equisetum arvense were obtained from a local shop in Brasov, Romania.The green composite materials were developed using natural materials, with beeswax and fir resin serving as the matrix and fir needles, rice, and The raw materials used for developing green composite materials are presented in Equisetum arvense grain diameter was under 0.5 mm.All these natural materials used for green composite preparation were dried and ground before their blending. After grinding the fir needles, the rice and (1)The base natural materials (beeswax and/or fir resin) were melted at a temperature of approximately 80–100 °C.(2)Equisetum arvense) were added in the proportions specified above.The reinforcing natural filler powders The natural material blend was mixed thoroughly.(4)The blend was poured into silicone rubber molds, as shown in The following steps were taken to prepare the green composite materials:The recyclable paper was prepared according to the process outlined in The green composites obtained after pouring the natural material blends onto the recyclable paper can be seen in All the natural composition blends were poured onto recyclable paper in the PLA molds.Bending and compression strength and Young’s modulus (E) for the composite structures (sandwich structures and wing sections) were performed on the WDW-150S universal testing machine with a constant crosshead speed of 10 mm/min for all test . The impact (resilience) strength of the green composites obtained was measured on a Galdabini Impact 25 equipment, Cardano al Campo, Italia, with 25 kJ maximum energy. Compression and bending tests were performed with a speed of 10 mm/s. The impact energy of the impact hammer was 5.5 J. Five samples were tested for each mechanical test property, and the average values are reported.Micrographs were obtained by using a scanning electron microscope (SEM), Hitachi, Japan, S3400N, type II, and the images were taken from the impact-fractured composite surface.Images of the fractured composite surfaces were taken using an optical microscope type Leica , Emspira 3 model.The mechanical, thermal, and durability properties of a composite are largely determined by the interfacial adhesion zone in the composite system. The strength of this zone depends on several factors, including the physical–chemical properties of each composite component, their size and shape, mass ratio, dispersion grade of fillers into the matrix composite, preparation technique, and technological parameters used for composite preparation. In this study, we evaluated the mechanical properties of the green composites in terms of impact, compression, and bending maximum force, as shown in Equisetum arvense powder (S4) and ground rice (S5) negatively impacted the resilience value of the beeswax-based samples (S2), likely due to their higher modulus of elasticity, which includes silica-based compounds and unplastified starch. Conversely, the addition of fir needle powders (S6) and fir resin (S8) led to an increase in shock resistance or resilience. The best resilience value was achieved with the S6 composite, which was based on beeswax and fir resin. Additionally, improvements in impact strength were recorded for S2, S6, S7, and S8, with the highest values found in S6 and S8 at 19.42 and 19.32 kJ/m2, respectively. These results can be assigned to the mechanical strength provided by fir resin, as well as the viscoelastic properties of the cellulosic fibers, as noted by Jakob et al. [b et al. . It is wb et al. ,42,43,44b et al. .Equisetum powder and beeswax (S7) and beeswax alone (S8) had a strong negative effect on the compressive strength of sample S3.Ground rice addition caused a slight decrease in compressive strength for the S5 sample, while the addition of fir needle powder caused a slight increase in compressive strength for the S6 sample. The sample based on fir resin (S3) showed the best value for compressive strength. However, the addition of Equisetum powders (S4), ground rice (S5), and fir resin with Equisetum powders (S6) led to an increase in the maximum bending force for sample S2. Among all the samples, composite S5 based on beeswax and ground rice demonstrated the best value for maximum bending strength. This can be attributed to the swelling of the rice fibers, as can be observed in the inset surface fracture image of S5 in In In this study, we compared the mechanical properties of the green composites, which were considered as the core materials for the final green products with those of similar commercial products from the automotive sector see . We mechThe results obtained from the mechanical tests on the proposed composites indicate that improvements and a different approach are necessary to further enhance these properties without sacrificing their advantages, such as being natural, ecological, recyclable, and sustainable. However, the improved physical–mechanical properties make these composites suitable for various applications beyond the automotive industry, including aeronautics and other fields where sound-absorbing panels are needed.It was also observed that high mechanical properties are not always required for materials used in the automotive industry, particularly for the lining of the engine hood and linear luggage, where good sound-absorbing properties are more important. Overall, the use of natural, sustainable materials in these applications can provide a more environmentally friendly solution while maintaining or even improving performance.To observe the effect of the natural material blend incorporation poured onto the recyclable paper matrix, optical images of the fractured green composites’ surfaces were analyzed using light microscopy. 2 for the green composites denoted as S2, S6, and S8, respectively.The observations from the light microscopy images show that the natural material blends were able to wet the paper core effectively. The dispersion of natural blends was remarkable for samples S2, S6, S7, and S8, with the blends encapsulating the paper core fibers, thereby adding mechanical strength to the resulting green composites. These findings confirm the results from the mechanical tests, particularly the high impact strength values of 19.16, 19.42, and 19.32 kJ/mScanning electron microscopy was performed to investigate the surface morphology and interface structure of the impact-fractured composite samples with good mechanical strength , as shown in Equisetum fibers) throughout the internal structure of the paper fiber cores. This behavior, particularly in the case of the S2 sample, confirms its mechanical performance, as the mechanical tests showed an approximately doubled impact strength compared to the recyclable paper-only reference. The interface failure is observed as a matrix failure, with tearing and shearing of the matrix visible. The images in The SEM images obtained from the fractured S2, S6, and S7 samples demonstrate a uniform morphology, indicating a high dispersion of the melted natural materials ;Further research is ongoing to determine the thermal and sound-absorbing properties of these composites, as well as finding new solutions to enhance their physical–mechanical properties. One possible solution is combining the benefits of eco-friendly filament printing, such as polylactic acid, with the sound-absorbing properties of these new materials.


COVID-19 has been causing significant mental health problems and other health-related issues. Despite the fact that COVID-19 has a significant impact on chronic disease patients, there is scant research on insomnia, common mental health disorders (CMD), and their associated factors among chronic disease patients.The purpose of this study was to assess the prevalence of insomnia and common mental disorders (CMD) and their associated factors among patients with pre-existing chronic NCDs in Sidama, southern Ethiopia.A multicenter cross-sectional study was undertaken between June 1 and September 1, 2021. The study included 633 participants. CMD and insomnia were assessed using a 20-item Self-Reported Questionnaire (SRQ-20) and a 7—item Insomnia Severity Index (ISI) scale, respectively. To describe the various variables, descriptive statistics were used. We performed multivariable logistic regression analysis to identify independent factors associated with CMD and insomnia. A value of p < 0.05 was considered statistically significant at a 95% confidence interval.The prevalence of insomnia and CMD was found to be 39.3% and 46.8%, respectively. Being merchant , having a diagnosis of diabetes mellitus , comorbid diagnosis , low social support  and moderate ), symptoms of insomnia  and poor quality of life (QOL)  were independent predictors of CMD. We also found out that, having cardiovascular disorders (CVDs) , CMD , and poor QOL  were significantly associated with insomnia symptoms.Our study suggests that substantially high prevalence of CMD and insomnia. Significant association between CMD and occupation, diagnosis, comorbidity, social support, insomnia, and QOL were found. We also revealed that having CVDs, CMD, and poor QOL were significantly associated with insomnia symptoms. Therefore, dealing with the mental health problems of patients with chronic NCDs is an essential component of public health intervention during the COVID-19 pandemic. Noncommunicable diseases (NCDs) are a group of chronic diseases that significantly increase morbidity and mortality in the community, including cardiovascular disease, stroke, cancer, diabetes, and mental health issues. NCDs have been exerting a significant global burden and considered as primary public health agenda for decades . NCDs acCOVID-19 also known as severe acute respiratory syndrome coronavirus-2 (SARS-CoV2), first appeared in the year 2020, causing a global health crisis and the collapse of several healthcare systems . The ongThe COVID-19 pandemic is claimed to be the cause of a significant increase in the global prevalence of mental disorders such as sleep problems, anxiety and depression. In addition, WHO expressed concern regarding the influence of COVID-19 on an individual’s mental health and psychosocial implications . EvidencPeople may exhibit signs of depression, anxiety, and stress such loneliness, denial, insomnia, despair, boredom, and irritability, and they even face a greater chance of committing suicide . IsolatiVs 24%)  .A study was conducted during the initial period of COVID-19 outbreak in China, and it indicated that 8.1% had moderate to severe level of stress, 16.5% had moderate to severe symptoms of depression, and 28.8% had moderate to severe symptoms of anxiety . A natioFurthermore, sleep disturbances were associated with higher levels of mental distress . Sleep iIt has been established that the COVID-19 pandemic significantly affects the development of the illness and survival of NCD patients. As a result, worries regarding the mental health of NCD patients have increased. Comorbid anxiety and depression make it difficult for patients to take their medications, which decreases therapeutic safety and efficacy and raises the risk of disability and death. Comorbid mental problems, however, are frequently ignored and sometimes not adequately treated . DespiteWe conducted a cross-sectional study at four hospitals in Sidama National Regional State, southern Ethiopia, between June 1 and September 1, 2021 . The Hawassa University comprehensive specialized hospital, with about 500 beds in southern Ethiopia, serves a population of over 18 million in the Sidama region and surrounding regions of southern Ethiopia, Oromia and Somalia. It is the only specialized hospital in the region. It was provided inpatient services for COVID-19 patients and isolation center in the region and surroundings. Yirgalem General Hospital is found in Yirgalem town and it is one of the General Hospitals in Sidama region serving about 4 million people in the region and nearby. Adare general hospital is located in Hawassa city and serves for communities from Hawassa and nearby cities. Leku primary hospital is one of the primary hospitals found in Sidama region located around 25 kilo meter away from Hawassa city.α/2)2 × p × (1 − p)/d2, where n is the sample size, z is the standard normal score set at 1.96, d is the desired degree of accuracy and p is the estimated proportion of the target population. By taking p = 50% (because there were no similar study in the area and to get adequate or maximum sample size), Zα/2 = 1.96 and d = 5%, the computed sample size was 384; and by taking 10% non-response rate, the total sample size computed was 422. Using design effect 1.5, our final sample size was estimated to be 633 . Sample size was proportionally allocated to each hospital based on the patient flow of the hospitals.In this study we have included patients with chronic NCDs such as diabetes, hypertension, chronic cardiovascular diseases, respiratory diseases such as asthma, and others who had regular follow-up visit at the selected hospitals. Individuals with pre-existing chronic medical illnesses receiving follow-up care in the outpatient departments (OPDs) of the four hospitals were contacted and requested to take part in the study if they met the following criteria: (I) patients above the age of 18 with confirmed chronic NCDs; (II) patients with stable clinical condition and able to understand the objective of the survey; and (III) patients with no known serious mental or neurocognitive problems. Patients with pre-existing chronic NCDs who were admitted to the emergency or inpatient units for any reason were not included in the study. The required sample size was estimated using single population proportion formula: , insomnia, and quality of life (QOL). The questionnaire was written in English before being translated into Amharic, the local language. The questionnaire was translated from English into Amharic by native speakers of the language who are fluent in English, then back-translated into English by other translators to guarantee consistency. Finally, the Amharic version of the questionnaire was used to collect data.Data were collected by nurses who had received 2 days of training on data collection processes and assessment tools. A pretest was performed on 5% of the sample to discover potential difficulties with the data collection procedures, as well as to assess the consistency of the questionnaires and the competency of the data collectors. The investigators reviewed each questionnaire for completeness on a regular basis during data collection.Social support of patients with pre-existing chronic NCDs was measured using the three-item Oslo social support scale (OSSS). The scale has a score of minimum 3 and maximum 14. It has three categories. A score of 3–8, 9–11, and 12–14 indicates poor, moderate, and strong social support, respectively .The World Health Organization developed the SRQ-20, a 20-item screening tool for common mental disorders . There aThe nature, intensity, and effects of insomnia are evaluated using the ISI, a seven-item self-assessment questionnaire . The folTo analyze the impact of the COVID-19 pandemic on QOL, we used an adapted version of 12 items , from thp-values of <0.05 were considered as statistically significant.For analysis, the data collected were entered into Epi-data version 3.1 and exported to SPSS version 24 for Windows. Various variables were described using descriptive statistics such as frequency, percentage, mean, standard deviation, and median. Binary and multivariable logistic regression were used to identify independent factors of insomnia and CMD. The Hosmer-Lemeshow test was used to assess model fitness. At 95% confidence interval (CI), A total of 633 patients with pre-existing chronic NCDs were involved in this study. Majority were male 357(56.4%), 410(64.8%) participants were married, 352(55.6%) were Protestant by religion and about one-fourth 175(27.6%) were illiterate. Of the total participants, about one-fifth 144(22.7%) were farmer by occupation and majority 353(55.8%) were urban residents. The mean age of the respondents was 46.49 ± 17.71 as described in About half 336(53.1%) of the participants were diagnosed with diabetes mellitus followed by hypertension 111(17.5%) and nearly one-third 200(31.6%) participants had comorbid diagnosis. Majority 364(57.5%) of the participants were ill for ≤5 years, 61(9.6%) and 49(7.7%) participants were using alcohol and khat in the past three months, respectively. Among the total participants, more than one-third 224(35.4%) and about half 332(52.4%) had poor and moderate social support, respectively. Moreover, 293(46.3%) of participants were poor QOL .The prevalence of insomnia and CMD were found to be 39.3% (95% CI = 35.3–43.3%) and 46.8% (95% CI = 42.8–50.6%), respectively as shown in In a multivariable logistic regression model, occupation, diagnosis, comorbid diagnosis, social support, insomnia, and quality of life were all significantly associated with CMD. When compared to government employees, being a merchant is 66%  less likely to develop CMD. Regression analyses revealed that having a diagnosis of diabetes mellitus  and a comorbid diagnosis  increased the likelihood of reporting CMD significantly more than having a diagnosis of hypertension and their counterparts. Poor social support  and moderate social support  were both associated with an increased risk of developing CMD. Individuals with symptoms of insomnia  and poor QoL  were more likely to report CMD as shown in The COVID-19 pandemic appears to be having a severe impact on the mental health of individuals with pre-existing medical conditions. In this study, we examined the prevalence and predictors of COVID-19 pandemic related common mental disorders (CMD) and insomnia in patients with chronic medical conditions in south Ethiopia. CMD and insomnia levels were surprisingly high, according to our research. Being a merchant, having diabetes mellitus, having a longer illness duration, having comorbid diagnoses, having low social support, having comorbid insomnia, and having a poor quality of life (QoL) were significant predictors of CMD. Additionally, a significant association between a high risk of insomnia and a diagnosis of cardio-vascular disorders, concurrent CMD, and poor QoL was found. The prevalence of insomnia and CMD indicates a need for mental health and psychosocial support (MHPSS) during the COVID-19 pandemic.CMDs such as anxiety and depression were found to be more common in pre-existing physical conditions with a higher risk of COVID-19 infection in previous studies , 55. OurHowever, lower prevalence were reported in Ethiopia (22.8%) , and IndThis result of this study revealed that the prevalence of insomnia among chronic medical conditions was found to be 39.3%. Previous investigations and systematic review reports in different situations and populations provided almost approximate results in line with our findings –72. SimiBeing a governmental employee increases the likelihood to have CMD as compared to merchants. This finding is consistent with a recent study . The civSimilarly, those with inadequate (poor and moderate) social support were more likely to have CMD than those with strong social support, which is consistent with previous studies , 88, 89.This study indicated that patients diagnosed with diabetes were more prone to develop CMD as compared to hypertension. Mental health problems such as depression is more likely to occur in people with diabetes –94. SeveIn this study, participants with CMD were more likely to be at risk to develop insomnia and vice versa. In general, there is evidence that mental health problems are associated to sleep disturbances and that insomnia is related to the psychological stress. That is, a bidirectional relationship between insomnia and psychological problems were clearly demonstrated . FurtherOur study also showed that participants who had poor QoL were more likely to develop CMD and insomnia. Similarly, recent studies have discovered that poor QoL is associated with insomnia and poor sleep quality , 108 andThere were certain limitations in this study. First, due to the study’s cross-sectional methodology, it was unable to demonstrate causal links between the variables investigated. Second, because all of the data was self-reported and the participants’ responses were not independently validated, social desirability bias and recall bias could have occurred. Third, because the study’s participants were all people with chronic illnesses, the findings cannot be generalized to the general public.This study highlights the prevalence of CMD and Insomnia among patients with chronic NCDs were found to be considerably high. Occupation, diagnosis, comorbid diagnosis, social support, insomnia, and quality of life were all significantly associated with CMD. We also found out that, having CVDs, CMD, and poor QOL significantly increases the likelihood of having insomnia symptoms. As a result, addressing mental health issues among patients with chronic CMD is an essential component of public health interventions during the COVID-19 pandemic.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Hawassa University, College of Medicine and Health Sciences, Institutional Review Board (IRB) with reference number IRB/076/13. The participants provided their written informed consent to participate in this study.MA, BD, AG, SH, and ET participated in the conception and designed the study and involved in the data collection. MA, BD, and SD do the analysis of the study. MA and SD prepares the manuscript for publication. BD, AG, SH, SD, and ET critically reviewed the manuscript. All authors contributed to the article and approved the submitted version.


Ulcerative colitis is a chronic inflammatory disease with high mortality and morbidity worldwide. It causes inflammation in the lining of the colon, resulting in several symptoms that negatively impact the quality of life. Unfortunately, there is currently no known cure for this condition. Therefore, it is crucial to explore alternative treatment approaches. This research aimed to investigate the anti-inflammatory and antioxidative effects of a combination therapy involving Sulfasalazine+Ezetimibe compared to Sulfasalazine alone in a rat model of ulcerative colitis. Forty adult rats were divided into four groups for this study. The groups consisted of a control group (negative control), an acetic acid group (positive control), an acetic acid+Sulfasalazine (100 mg/kg per day) group, and an acetic acid+Sulfasalazine (50 mg/kg)+Ezetimibe (5 mg/kg) group. Rats were treated for one week, and colitis was induced by administering 2 ml of 4% (v/v) acetic acid inter-rectally. After sacrifice, the colonic tissue homogenate was analyzed for several markers, including proinflammatory cytokines , oxidative stress markers , and adhesive molecule markers . Sulfasalazine and the combination of Sulfasalazine+Ezetimibe significantly reduced the colonic levels of TNF-α, IL-1β, NF-κB, MDA, and E-selectin in the homogenate. However, the combination therapy of Sulfasalazine and Ezetimibe demonstrated a superior effect. Ulcerative colitis is a chronic disease characterized mainly by inflammation and ulcers in the lining of the large intestine, part of the gastric intestinal tract (GIT). This condition can cause a range of symptoms that significantly impact the quality of life. Symptoms may include diarrhea, abdominal pain, and fatigue, leading to malnutrition and weight loss , 2. FurtThe etiology of ulcerative colitis remains unknown, but it is believed to involve irregular inflammation in response to antigens, whether of internal, microorganism, or environmental origin, resulting in the propagation and worsening of this inflammation , 4. SeveIt is important to note that early treatment of ulcerative colitis can improve outcomes and prevent complications. Treatment can reduce the severity and frequency of symptoms, leading to an improved quality of life. Additionally, it can prevent or delay the need for surgery, which is often associated with complications. Early treatment also reduces the risk of colon cancer, a severe complication of ulcerative colitis. Therefore, early treatment plays a crucial role in managing ulcerative colitis. Despite significant progress in its treatment, the long-term use of certain drugs can lead to drug-induced toxicity and high relapse rates, which limits the effectiveness of established treatments. Therefore, novel strategies for restoring the altered immune response are needed , 9.Sulfasalazine is a medication commonly used to treat inflammatory bowel disease (IBD). It has been found to effectively reduce inflammation in the gut and joints. However, there are also associated side effects with the use of Sulfasalazine. In this study, we will discuss the uses and mechanism of action of Sulfasalazine, as well as the potential side effects and limitations . The effThere are several controlled-release systems and dosage forms to ensure that 5-ASA reaches the site of inflammation, such as Olsalazine, which is a prodrug disintegrated in the GIT to form Mesalamine, a potent medication for the treatment of ulcerative colitis, available in various forms, including rectal, oral, and enema dosage forms . MedicatOn the other hand, Ezetimibe is a lipid-lowering agent primarily used to treat hypercholesterolemia. Its mechanism of action involves the inhibition of intestinal absorption of phytosterols and related sterols, including cholesterol. In addition to lowering cholesterol, Ezetimibe has gained attention in recent years for its putative anti-inflammatory properties. Studies have shown that Ezetimibe can reduce inflammation in experimental models of atherosclerosis and rheumatoid arthritis. This has sparked interest in exploring its therapeutic potential in other inflammatory conditions, including IBD .Combination therapy, involving the simultaneous use of two or more drugs with complementary mechanisms of action, has gained attention in the field of IBD treatment. The rationale behind combination therapy is to enhance efficacy, minimize side effects, and potentially target multiple pathways involved in the pathogenesis of the disease .In light of the promising individual effects of Sulfasalazine and Ezetimibe, we hypothesized that their combination might result in the best therapeutic effects in colitis management. Therefore, this study aimed to investigate the comparative treatment effects of sulfasalazine alone and the combination of Sulfasalazine and Ezetimibe in a rat model with induced colitis.Ezetimibe is one of the azetidinone group cholesterol absorption inhibitors and is commonly used as a supplementary treatment to dietary modifications and statin therapy for individuals with hypercholesterolemia . The afoThis study aimed to investigate the comparative treatment effects of a combination of Sulfasalazine and Ezetimibe versus Sulfasalazine alone in a rat model with induced colitis. Sulfasalazine is a commonly used medication for treating IBD, while Ezetimibe is an agent primarily used for lowering cholesterol levels. The rationale behind combining these two drugs was to explore their potential effects in ameliorating colitis.In our research, adult male albino rats weighing 200–220 g were employed. The rats were housed in polypropylene clean cages in a relatively stable condition, with a temperature of about 24–25 degrees Celsius, humidity of 35–60 percent, and a 12/12 h (day to night cycle). We stopped rat feeding about 24 hours before the induction of colitis to ensure deprivation and complete induction of colitis, but they received water only. The rats were housed in enclosures featuring broad wire mesh flooring as a preventative measure against coprophagy. Before inducing colitis, the rats were deprived of water for 2 hours .et al. [Rats underwent a fasting period of at least 24 h prior to the induction of colitis. This procedure was performed to ensure proper induction by clearing the colon of fecal matter. Nevertheless, the rats had free access to tap water during this period. The induction of colonic ulceration was conducted experimentally with a modified version of the procedure recommended by Mousavizadeh et al. . In thisThe experiments were divided into 4 categories (ten rats for each group). Group I was non-treated and was the negative control . In the other groups, rectal administration of 4% acetic acid (v/v) induced colitis. Group II represented positive control and received normal saline orally, group III was treated orally with Sulfasalazine (100 mg/kg), and Group IV was treated orally with a combination of Sulfasalazine (50 mg/kg) and Ezetimibe (5 mg/kg). In all groups, treatment lasted for 7 days. The duration of treatment was determined according to prior studies on experimental colitis , 21.The solutions of Sulfasalazine and the Sulfasalazine+Ezetimibe mixture were prepared prior to administration. These drugs were suspended in distilled water. The recommended dosage of Sulfasalazine was 100 mg/kg .Upon the completion of the experiment, the rats were euthanized with an excessive dose of diethyl ether. The colon was expeditiously excised subsequent to abdominal dissection. A longitudinal incision was made on the colon, delicately irrigated with normal saline. Colon samples were collected, rinsed with PBS , and weighed at a temperature of -80 °C. The tissue samples were sliced into small fragments and subsequently homogenized in a specified quantity of PBS (1 g of tissue in 9 ml of PBS) with a homogenizer. Subsequently, the homogenate was centrifugated at 5000 commotions per minute for 15 min . We measData were summarized, analyzed, and presented using the Statistical Package for Social Sciences (SPSS) version 23. We used the mean and standard deviation to express quantitative variables numerically. One-way ANOVA was used to examine differences in the means of quantitative variables across groups, followed by the post-hoc least significant difference test for evaluating differences in the means of quantitative variables within groups. A p-value of <0.05 indicated significance .The levels of TNF-α, IL-1β, and NF-κB in the colon tissue homogenate were significantly increased in the colitis group  compared to the healthy control group . The Sulfasalazine+Ezetimibe combination had a statistically significant and higher effect in reducing the levels of TNF-α (147.7±31.12 pg/ml), IL-1β (162.4±28.19 pg/ml) and NF-κB (1.3±0.82 pg/ml) compared to Sulfasalazine , as shown in As displayed in For tissue level homogenate oxidative stress markers (MDA and MPO), there were highly significant increases in the colitis group  compared to the healthy control group . The combination of Sulfasalazine+Ezetimibe was more effective in reducing MDA levels (117.7±16.22 pg/ml) than the Sulfasalazine group (137.56±24.69 pg/ml). The homogenate level of MPO in the Sulfasalazine+Ezetimibe group and the Sulfasalazine group was 1.60±0.78 ng/ml and 1.80±0.62 ng/ml, respectively .This research showed that Sulfasalazine+Ezetimibe combination significantly reduced the tissue homogenate levels of NF-κB, TNF-α, IL-1β, oxidative markers , and adhesion molecules . Unfortunately, no previous studies investigated the effects of the Sulfasalazine+Ezetimibe combination on colitis. A previous study showed that Ezetimibe exerts pharmacological, anti-inflammatory, and immunomodulatory effects, reduces cytokine production, inhibits macrophages, and reduces the levels of circulating inflammatory cytokines. Meanwhile, the mechanism by which sulfasalazine improves inflammatory response in colitis is merely attributed to its anti-inflammatory and antioxidant effects , 26. Thiet al. (2009) primarily utilized Ezetimibe as a lipid-lowering agent, and according to the result of the present study, it has anti-inflammatory activity and lower adverse effects than Sulfasalazine [Furthermore, a study by Visschers salazine . Hence, In conclusion, the combination of Sulfasalazine and Ezetimibe showed superior therapeutic efficacy in the rat model of induced colitis compared to Sulfasalazine monotherapy. These findings suggest that the dual targeting of inflammation and lipid metabolism may hold promise as a potential therapeutic approach for managing IBD. Further studies are warranted to elucidate the underlying mechanisms and validate these findings in human clinical trials. The combination significantly reduced the levels of pro-inflammatory cytokines TNF-α, IL-1β, and NF-κB, and adhesion molecule E-selectin. The levels of adhesion molecule ICAM-1 and oxidative markers MPO were also reduced, but the difference was not significant. These findings suggest that the Sulfasalazine and Ezetimibe combination could be a promising therapeutic strategy.


Although acute myocardial infarction (AMI) requires timely intervention, limited nationwide data is available regarding the association between disruption of emergency services and outcomes of patients with AMI during the coronavirus disease 2019 (COVID-19) pandemic. Moreover, whether diabetes mellitus (DM) adversely affects disease severity in these patients has not yet been investigated.This nationwide population-based study analyzed 45,648 patients with AMI, using data from the national registry of emergency departments (ED) in Korea. Frequency of ED visits and disease severity were compared between the COVID-19 outbreak period (year 2020) and the control period (the previous year 2019).p-values < 0.05). A longer duration from symptom onset to ED visit (p = 0.001) and ED stay (p = 0.001) and higher rates of resuscitation, ventilation care, and extracorporeal membrane oxygen insertion were observed during the outbreak period than during the control period . These findings were exacerbated in patients with comorbid DM; Compared to patients without DM, patients with DM demonstrated delayed ED visits, longer ED stays, more intensive care unit admissions (p < 0.001), longer hospitalizations (p < 0.001), and higher rates of resuscitation, intubation, and hemodialysis  during the outbreak period. While in-hospital mortality was similar in AMI patients with and without comorbid DM during the two periods , patients with DM who had other comorbidities such as chronic kidney disease or heart failure or were aged ≥ 80 years had higher in-hospital mortality compared with those without any of the comorbidities .The number of ED visits by patients with AMI decreased during the first, second, and third waves of the outbreak period compared to the corresponding time period in the control period (all During the pandemic, the number of patients with AMI presenting to the ED decreased compared with that of the previous year, while the disease severity increased, particularly in patients with comorbid DM. In aAcute myocardial infarction (AMI) is a sequelae of ischemic cascade and myocardial necrosis that requires prompt revascularization . Several2.2.1.This nationwide population-based cohort study used data from the National Emergency Department Information System (NEDIS) registry of the National Emergency Medical Center (NEMC) in South Korea. Since 2016, demographic and clinical data of patients visiting all types of emergency healthcare facilities—regional emergency medical centers, local emergency medical centers, and local emergency medical institutions—have been prospectively collected in NEDIS . This st2.2.n = 49,720; n = 23,623) or the “outbreak period” , according to the date of their ED visit. The outbreak period was further divided into four time periods according to the number of confirmed COVID-19 cases: the first wave, weeks 7–16; the post-first wave, weeks 17–30; the second wave, weeks 31–42, and the third wave, weeks 43–53 . The study protocol was approved by the Institutional Review Board of Korea University (IRB number 2022GR0171).Patients who visited the regional or local emergency medical centers between 2019 and 2020 and were given a primary diagnosis of ICD-10 codes I20 or I21 at discharge from the ED or hospital were initially screened ], and in-hospital mortality. KTAS ranges from level 1 to 5, with level 1 being the most severe: level 1, resuscitation; level 2, emergency; level 3, urgency; level 4, less urgency; and level 5, non-urgency. The procedure codes for intubation, hemodialysis, and ECMO are listed in Supplementary Table 2. Study outcomes were compared between the control and outbreak periods and between patients with and without DM. DM was defined as a primary or secondary diagnosis of ICD-10 codes E10, E11, E12, E13, or E14. In addition, patients with other severe comorbidities such as chronic kidney disease (CKD) stage 4 or 5 (ICD-10 codes N18.4 or N18.5), heart failure (ICD-10 code I50), or old age (≥ 80 years) were compared with those without any of the comorbidities.2.4.t-tests were performed to compare numerical variables, including blood pressure, pulse rate, respiratory rate, and body temperature. Mann–Whitney U-test with continuity correction was performed to compare continuous variables, including hours taken from symptom onset to ED visit, duration of ED stay, and duration of hospital stay.R statistics software version 4.1.3  and R packages, including ggplot2, lubridate, readxl, and dplyr, were used for statistical analysis. Two-sample tests for equality of proportion were performed to compare the rates, including age groups, sex, KTAS level, distribution after emergency care, PCI, bypass surgery, intubation, hemodialysis, ECMO usage, and in-hospital mortality rates. Welch’s two-sample 3.3.1.p < 0.001), 450 (control) vs. 399 (second wave) visits (p = 0.004), and 468 (control) vs. 433 (third wave) visits (p = 0.008). However, no difference was observed during the post-first wave . Similar findings were noted in patients with underlying DM (p = 0.012), 87 (control) vs. 73 (second wave) visits (p = 0.004), and 88 (control) vs. 79 (third wave) visits (p = 0.009). However, for these patients, comparable numbers of ED visits were observed during the post-first wave .According to the NEDIS registry, there were a total of 6,146,688 ED visits in 2019 and 4,809,661 in 2020. During the outbreak period, 22,025 patients visited the ED owing to AMI and underwent PCI or bypass surgery, while 23,623 patients visited during the control period. The frequency of ED visits during the outbreak and control periods is shown in lying DM , with dr3.2.p = 0.100). Almost all patients underwent PCI . The time from symptom onset to ED visit was significantly longer in the outbreak period than in the control period . In addition, the duration of ED stay was significantly longer during the outbreak period than during the control period . After emergency care, patients were either transferred due to medical shortage, admitted to the general ward, admitted to the intensive care unit (ICU), or died; there was no difference in these outcomes between the two periods. The duration of total hospital stay was also similar between the outbreak and control periods .The demographics and baseline clinical characteristics of patients with AMI according to their ED visit periods are summarized in p < 0.001). Moreover, the intubation  and ECMO insertion rates  were higher in the outbreak period than that in the control period. The in-hospital mortality was 4.3% in the outbreak and 4.0% in the control periods, although the difference was not statistically significant (p = 0.086).Differences in major clinical outcomes were compared in patients with AMI between the two periods, as shown in 3.3.p = 0.002). The time from symptom onset to ED arrival  and duration of ED stay  was significantly longer in patients with DM than in those without DM. Notably, compared to patients without DM, more patients with DM were admitted to the ICU  and were less frequently admitted to the general ward . In addition, the duration of hospital stay was significantly longer in the DM group than in the non-DM group .Given the increased severity of the disease course in patients with AMI during the outbreak period, we further assessed the clinical differences according to their DM status. In 2020, 4,071 patients with DM and 17,954 without DM visited the ED for AMI . The prop = 0.021). The intubation rate was significantly higher  and more patients underwent dialysis  in the DM group compared to the non-DM group. Despite this, the in-hospital mortality was similar between the two groups .When comparing the major clinical outcomes based on DM status , the pro3.4.p < 0.001) as well as the duration of ED stay . Admission rate to ICU were also higher in patients with combined comorbidities . Major clinical outcomes were compared between the two groups (p < 0.001) and dialysis  in patients with severe comorbidities than the controls. Accordingly, the in-hospital mortality was significantly higher in patients with combined comorbidities than those with none .In adjunction with DM, patients with other severe comorbidities including CKD stage 4 or 5, heart failure, or old age were compared with those without any of them . The timo groups  which sh4.This study analyzed nationwide data on emergency care facilities in Korea to evaluate the patterns of ED visits and clinical outcomes of patients with AMI visiting the ED, with a particular focus on the impact of comorbid DM in patients with AMI, during the COVID-19 pandemic. We observed a decrease in patients with AMI presenting to the ED during the outbreak period compared with the previous year. Moreover, significantly longer durations of both symptom onset to ED visit and ED stay were noted, in addition to higher rates of resuscitation, ventilation care, and ECMO insertion, during the outbreak period compared to the control period. These findings were present and exacerbated in patients with AMI and underlying DM; compared to patients without DM, patients with AMI and underlying DM were more frequently admitted to the ICUs, hospitalized longer, and had higher rates of resuscitation, intubation, and hemodialysis during the pandemic. Notably, when patients with DM had other comorbidities such as CKD or heart failure or were aged ≥ 80 years, their in-hospital mortality was increased compared to those without any of the comorbidities. Taken together, while there were fewer patients with AMI who presented to the ED during the COVID-19 outbreak, their disease severity was higher, especially in patients with AMI and underlying DM. To the best of our knowledge, this is the largest study of its kind to date that used a comprehensive national dataset to cover various aspects of the utilization of emergency care services as well as clinical outcomes of patients with AMI, while highlighting the impact of underlying DM in patients with AMI, during the COVID-19 outbreak.Unique trends in ED visits have been reported from previous respiratory infection outbreaks. During the SARS outbreak in 2003, a reduction in total ED visits was observed , althougOur study showed that during the outbreak period, the volume of ED visits by patients with AMI decreased, while the severity of the disease increased. Disease severity was assessed with the final KTAS scores at ED discharge; the proportion of major procedures performed, such as intubation, hemodialysis, and ECMO; and in-hospital mortality. KTAS scores and the proportion of major procedures performed were higher during the outbreak than during the control period. Increased rates of intubation and ECMO insertion in patients with AMI who underwent revascularization may reflect higher rates of cardiac arrest, as previously reported . These iAnother important finding of this study is that DM exacerbated the clinical course of patients with AMI during the pandemic, which has not yet been evaluated in other studies. It is well established that DM is a common poor prognostic factor in COVID-19 cases . As expeThis study has some limitations. First, claims data from the NEDIS registry was used, which limits the assessment of laboratory results or medication use. Second, to improve the accuracy of the diagnosis of AMI, we selected patients with both relevant ICD-10 codes and procedure codes; thus, we could not compare the proportion of PCIs or bypass surgeries performed on patients with AMI during the outbreak and control periods. Despite these limitations, the strength of our study lies in comprehensively addressing all aspects of emergency care of patients with AMI during the COVID-19 period—details of changes in pattern in the frequency of ED visits were calculated at 1-week intervals and compared with the corresponding control periods. Additionally, various clinical characteristics of the patients with AMI, including the procedures that have been performed, with a focus on the impact of comorbid DM, were elucidated, using a nationwide dataset of emergency care facilities.5.In conclusion, during the 2020 COVID-19 outbreak, the number of patients with AMI presenting to the ED decreased compared with that of the previous year, while the disease severity increased, particularly in patients with comorbid DM. This study sheds light on the fact that careful attention should be paid beyond the COVID-19 infection itself and to the non-COVID-19-related diseases such as AMI, especially when high-risk co-morbidity exists, such as DM.http://dw.nemc.or.kr).Publicly available datasets were analyzed in this study. This data can be found at: National Emergency Department Information System repository in South Korea . Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.ES researched the data, wrote, reviewed and edited the manuscript. JH researched and analyzed the data, and reviewed the manuscript. SP researched the data and contributed to methodology. MP, AJ, KC, and SB reviewed and edited the manuscript. HY researched the data, and reviewed and edited the manuscript. All authors contributed to the article and approved the submitted version.This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF), South Korea, funded by the Ministry of Education (NRF-2020R1I1A1A01072592 and NRF-2021R1A2C2008792) and by the Korea Medical Device Development Fund grant funded by the Korean government .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Cancer-related hypercalcemia is a common finding typically seen in patients with advanced cancer and occurs in about 20 to 30 percent of cases. The most common cause of hypercalcemia in hospitalized patients is hypercalcemia due to malignancy.This clinical problem is seen in patients with both solid tumors and patients with hematologic malignancies. Hypercalcemia is associated with a poor prognosis in oncology patients. This pathologic condition can occur due to many different mechanisms but is usually caused by abnormal calcium use resulting from bone resorption, intestinal absorption, or renal excretion. Hypercalcemia may present with a wide range of symptoms ranging from gastrointestinal system symptoms to neurologic symptoms. Timely diagnosis and initiation of treatment by the physician significantly reduce the risk of complications. Treatment aims to decrease serum calcium by increasing calciuresis, decreasing bone resorption, and decreasing intestinal calcium absorption. The mainstays of treatment are IV hydration, bisphosphonates and calcitonin, denosumab, and in some patients, prednisone, and cinacalcet. Patients with underlying advanced kidney disease and refractory severe hypercalcemia should be evaluated for hemodialysis. Every physician dealing with oncology patients should know the fastest and most effective management of hypercalcemia. We aimed to contribute in this sense. Sympt2Calcium balance refers to the state of calcium stores in the body, especially in the bone. Bone calcium balance can be neutral, positive, or negative, depending on several factors, including growth, aging, and acquired or inherited disorders. Calcium homeostasis refers to the hormonal regulation of ionized serum calcium by parathyroid hormone, 1,25-dihydroxyvitamin D , and serum ionized calcium itself, and these factors together regulate calcium transport in the intestine, kidney, and bone –8 Figu. The sec2.1The most common cause of hypercalcemia in patients with solid tumors is the secretion of PTHrP . This isThe structural difference after the first 13 amino acids of the molecule explains its immunologic difference from PTH. PTHrP is less likely than PTH to stimulate the production of 1,25-dihydroxyvitamin D, so the measurement of 1,25-dihydroxyvitamin D in patients with PTHrP-mediated hypercalcemia may be variable , 16. Typ2.2In normal individuals, 25-hydroxyvitamin D  is converted to 1,25-dihydroxyvitamin D  through 1-hydroxylase in the renal tubules, under the influence of PTH . FibroblUncontrolled production of 1,25-dihydroxyvitamin D  is the cause of almost all cases of hypercalcemia in Hodgkin lymphoma and about one-third of cases of non-Hodgkin lymphoma , 21. HypHigh serum 1,25-dihydroxyvitamin D concentrations may contribute to hypercalcemia by increasing both intestinal calcium absorption and bone resorption. Laboratory evaluation of these patients typically reveals low or suppressed serum PTH and elevated 1,25-dihydroxyvitamin D levels .2.3Hypercalcemia due to bone resorption occurs as a result of the release of mediators, which increase osteoclastic activity by tumor cells in the bone. The soluble protein RANKL, a member of the TNF family, is a central regulator of osteoclast formation, activity, and survival. This protein is synthesized by osteoblasts and T cells and directs the differentiation and activation of osteoclasts . HematopIn addition, multiple RANKL-independent osteoclast (OCL) stimulatory factors, including macrophage-derived protein MIP-1a, ILs 3, -8, -6, -17, -18, and Activin A, are produced or induced by cancer cells . MIP-1α Apart from these three main mechanisms, there are other less common causes of hypercalcemia due to malignancy.2.4Tumors secreting ectopic PTH have been reported as case reports in the literature . Example2.5Another rare cause of hypercalcemia is pseudohypercalcemia. This is due to measurement errors due to calcium binding to an abnormal immunoglobulin. It is possible to distinguish this using atomic absorption spectrophotometry .2.6The miRNAs act as subtle modulators in maintaining bone homeostasis. Basic evidence that miRNAs are essential for osteoclastogenesis is provided by genetic studies that delete DICER1, an enzyme essential for their biogenesis . DICER-d3Symptoms of hypercalcemia depend on at least two factors: the degree of hypercalcemia and the rate of change in serum calcium. Degrees of hypercalcemia relative to serum total calcium level are as follows: mild hypercalcemia, 10.5 to 11.9 mg/dL; moderate hypercalcemia, 12 to 13.9 mg/dL; and severe hypercalcemia, 14 mg/dL or above . Mild hyIt is important to note that at least two factors, such as the degree of hypercalcemia and the rate of its development, play a role in the development of clinically overt hypercalcemia. Patients with malignant hypercalcemia develop hypercalcemia at a very high level and in a short time, and therefore they are more symptomatic than patients with other causes of hypercalcemia . The majHypercalcemia impairs the concentration ability of the kidney . TubularNeuropsychiatric symptoms such as apathy, mood changes, and fatigue are often seen as symptoms of hypercalcemia, which can be overlooked and can be attributed to the underlying neoplasm. In oncology patients, muscle strength defect leads to mobility restriction, which leads to more calcium resorption from the bone and increases hypercalcemia . As hypeCardiovascular system findings are seen as a shortening of the QT interval on electrocardiograms . MalignaBone pain is a common symptom, both due to the malignancy itself and hypercalcemia. Bone pain may be associated with increased intramedullary pressure, ischemia, or the presence of metastases within the bone causing areas of microfracture, but the symptom is also present in the absence of demonstrable metastatic disease .4The first evaluation of patients with clinical signs of hypercalcemia starts with serum calcium measurement. Serum calcium is the sum of the physiologically inactive carrier-bound calcium and the active form of serum calcium, ionized calcium . TherefoCorrected calcium = Total calcium + [0.8 × ]Protein levels and thus calcium levels may be elevated in patients with severe dehidratation . It is iThe next step in the evaluation of a patient with malignancy-related hypercalcemia consists of measuring both PTH and PTHrP. PTH and PTHrP are similar molecules; therefore, both will not rise at the same time unless there is more than one cause. In most cases of malignancy, serum PTH levels appear to be suppressed or normal . High-noCASR, AP2S1, or GNA11 genes  may be valuable for the assessment of familial hypocalciuric hypercalcemia . If FeCa11 genes . However4.1The main goal in the treatment of hypercalcemia is to find the underlying cause and initiate treatment Table 1.4.1As mentioned before, patients with hypercalcemia present with nausea, vomiting, inadequate hydration due to altered mental status, and a dehydrated state due to nephrogenic diabetes insipidus caused by hypercalcemia , 67. In 4.2Calcitonin is a potent hypocalcemic hormone produced by the C-cells of the thyroid . Pharmac4.3Bisphosphonates inhibit osteoclastic bone resorption by binding to hydroxyapatite binding sites on bone surfaces . When OCIn addition to their inhibitory effects on OCs, bisphosphonates appear to have a beneficial effect on osteoblasts. The mechanism of this effect has been attributed to connexin 43, a gap junction protein that facilitates the activation of protein kinases. However, this anti-apoptotic effect probably does not contribute significantly to the anti-osteoporotic efficacy of bisphosphonates above their potent antiresorptive effects .Bisphosphonates should be given within 48 hours of diagnosis at the latest because they take approximately 2 to 4 days to take effect. Pamidronate is given as 60 to 90 mg IV over 4 to 24 hours . ZoledroThe most common adverse effect of bisphosphonates is related to impaired renal function. We have already mentioned the adjustment required for this. Other common adverse effects include bone pain and flu symptoms during the first 1 to 2 days after the infusion. Osteonecrosis of the jaw, which is very rare but very important for the patient’s quality of life, can be seen in patients who receive high-dose and long-term treatment, those who have invasive dental procedures during treatment, and patients with poor oral care , 85.4.4Glucocorticoids help lower serum calcium levels by several mechanisms. Glucocorticoids can suppress the synthesis of extrarenal calcitriol through activated mononuclear cells in the lung and lymph nodes. Namely, by inhibiting 1-alpha hydroxylase, they inhibit 1,25(OH)2 D synthesis and thus calcium absorption from the intestine . In addi4.5Denosumab is a humanized monoclonal antibody that inhibits the binding of RANKL with its receptor RANK . It is tThe adverse-effect profile of denosumab is also different from that of bisphosphonates. Denosumab, unlike bisphosphonates, is not excreted by the kidney and, as a result, there is no restriction on its use in patients with chronic kidney disease or a decrease in GFR for any reason, for whom bisphosphonates are used with caution or contraindicated . Given t4.6Cinacalcet directly decreases PTH levels by increasing the sensitivity of the calcium-sensing receptor to extracellular calcium, thus leading to a decrease in serum calcium levels . The dru4.72 IV over 24 hours for 5 days (Gallium nitrate is thought to exert its hypocalcemic effect by inhibiting calcium absorption from bone . Galliumr 5 days . It is w4.8Dialysis is the method used for the treatment of patients in whom optimal hydration cannot be achieved safely due to heart or kidney failure or who have hypercalcemia unresponsive to other treatments . It can 5Hypercalcemia due to malignancy is a very important issue in terms of both being the most common cause of hypercalcemia and affecting the prognosis of patients with cancer. Hypercalcemia can present with a wide range of findings from mild symptoms to life-threatening symptoms. Hematology,oncology, internal medicine,and palliative care specialists should have sufficient knowledge about the diagnosis and management of hypercalcemia.All authors meet the ICMJE authorship criteria and were involved in the whole writing process.


In this study, a novel technique for the quantification of the human chorionic gonadotropin (hCG) hormone using localized surface plasmons and a tapered optical fiber decorated with gold nanoparticles (Au-NPs) is reported. The tapered optical fiber fabrication process involves stretching a single-mode optical fiber using the flame-brushing system. The waist of the tapered optical fiber reaches a diameter of 3  The measurement of different concentrations of the hCG hormone plays a significant role in detecting various stages of pregnancy and serves as a potential biomarker for the detection and localization of different types of cancers, such as breast ,2,3, proQuantification and detection systems, especially those based on optical fiber, are gaining significant importance in hCG hormone detection ,17,18. TIn 2018, a method for detecting the hCG hormone using electrochemical transducers, aided by lateral flow analysis (LFA) test strips and a transducer, was reported. The system mainly consists of two copper electrodes attached to the LFA strips, allowing them to measure concentrations of 25 mIU/mL, 100 mIU/mL, 200 mIU/mL, 1000 mIU/mL, 5000 mIU/mL, and 10,000 mIU/mL. Measurements of resistivity changes upon interaction with the bioreceptor (hCG antigen) showed changes of 25 mIU/mL for every 10 M hormone .In 2020, a study on hCG hormone detection using a single-mode D-shaped hollow-core optical fiber as a transducer was conducted . To creaThe use of fiber optic technology and the study of the surface plasmon resonance (SPR) phenomenon have improved the detection of optical parameters in biological solutions due to their high real-time sensitivity, particularly in medical applications ,28,29. IThe main drawbacks of the systems reported so far include the use of multiple chemical processes for optical fiber functionalization. In the case of electrochemical transducers, their manufacturing involves several costly stages, complex electronic instrumentation is required to monitor the output response, and specialized laboratories with controlled environments are necessary. In this study, we report on a new method for quantifying the hCG hormone using localized surface plasmons with a specially prepared tapered optical fiber coated with gold nanoparticles. The fabrication process involves stretching a single-mode optical fiber to a diameter of 3 µm using a flame-brushing system, followed by decorating the taper with 100 nm Au-NPs using the drop-casting technique and a 1550 nm laser source. The developed measurement system shows promising potential for applications in both biomedical and industrial settings.The tapered optical fiber was fabricated using a single-mode optical fiber, SMF-28, using the flame-brushing technique shown in obtained . In FiguThe optical setup arrangement for the tapered optical fiber decoration involving drop-casting and laser radiation techniques is shown in An optical power meter  was connected to the end of the tapered optical fiber to monitor the optical power propagating through it, alongside a spectrum analyzer , to obtain the spectral response of the samples. Optical radiation of approximately 34 mW was supplied into the tapered optical fiber, which was positioned on a glass slide. Subsequently, the taper waist was decorated with 100 nm Au-NPs through the withdrawal of 0.2 mL of Au-NPs suspended in citrate buffer . This solution was then introduced into an ultrasonic bath for homogenization. A droplet of the Au-NPs solution (0.7 opipette a 32]. O. OμL) waA solution of 0.1 mg of the hCG hormone  was prepared in 10 mL of distilled water and placed in an ultrasonic bath for 30 s to homogenize the solution. From this solution, six samples with the following hCG hormone concentrations were prepared: 1 mIU/mL, 10 mIU/mL, 100 mIU/mL, 1000 mIU/mL, 10,000 mIU/mL, and 100,000 mIU/mL.As mentioned before, the optical power through the tapered optical fiber with Au-NPs was 34 mW, with an output optical power of 5.5 mW. Then, a drop of each hCG hormone sample  in the range of 4000 to 500 cmectively , indicatFurthermore, the analysis through fluorescence spectroscopy was performed within a wavelength range of 350 to 1050 nm using a spectrophotometer (Ocean Optics) equipped with a 365 nm excitation lamp. For this analysis, 500 spectrum , a distiIn the waist of the tapered optical fiber, the electric field of the evanescent wave amplifies due to the localized surface plasmons (LSPs) generated by the nanoparticles and laser radiation .In the experiments, it was observed that as soon as the amplified evanescent wave interacts with the hCG hormone, an immediate optical power response is generated. This response is observed from the optical output power of 5.5 mW mentioned above, obtaining the following: 4.45 mW for 1 mIU/mL, 4.4 mW for 10 mIU/mL, 3.54 mW for 100 mIU/mL, 3.32 mW for 1000 mIU/mL, 2.78 mW for 10,000 mIU/mL, and 2.5 mW for 100,000 mIU/mL. The calculated standard deviation is The results obtained show that at lower concentrations of the hCG hormone, the normalized optical power response is higher and gradually decreases as the hCG concentration increases. This suggests an inverse relationship between the hCG concentration and the optical power response, where higher hCG concentrations result in a lower normalized optical power response. This behavior is attributed to the LSP phenomenon.The LSP creates a close electric field around the Au-NPs; when there is a constructive interaction between this field and the evanescent field in the waist of the tapered optical fiber, the evanescent electric field is amplified, as shown in In this scheme, both the electric field generated by the laser and the evanescent field existing in the waist of the tapered optical fiber are presented in red (EIt is considered that with higher concentrations of the hCG hormone, the interaction or energy absorption by the amplified evanescent fields increases, resulting in a decreased optical power response, and vice versa. The molecular groups responsible for absorbing the energy of the evanescent fields are those that compose the hCG hormone, particularly the C=O functional groups found in the lipids and proteins of the It is important to mention that the amplification of the evanescent field leads to a greater interaction with the hCG hormone, even at low concentrations, as shown in the graph in The spectral analysis was achieved when depositing the different concentrations of the hCG hormone on the tapered optical fiber decorated with gold nanoparticles. In this case, a similar spectral behavior was observed as in previous reports ,37; therIn this work, we carried out a study on the quantification of hCG hormone concentrations and their corresponding optical power responses using a tapered optical fiber decorated with Au-NPs. Our experimental results demonstrate an inverse relationship, where higher hCG hormone concentrations lead to diminished normalized optical power responses. This phenomenon arises from the LSP effect, which intensifies the electric field around 100 nm Au-NP-decorated tapered optical fibers with a diameter of 3 µm. Through the utilization of gold nanoparticles, this research successfully broadened the detection range and improved resolution, spanning a concentration range from 1 mIU/mL to 100,000 mIU/mL. Optical power responses exhibited distinct behaviors as hormone concentrations increased, driven by the absorption of evanescent fields by the hCG hormone. Notably, the study accurately quantified hCG concentrations as low as 1 mIU/mL, highlighting its potential for early pregnancy detection and the diagnosis of certain cancers, as these typically present with hCG hormone concentrations ranging from 16 mIU/mL to 40 mIU/mL.


This study was conducted to characterize semen traits (ejaculate volume (VOL), mass motility (MM), sperm livability (LS), percentage of abnormal sperms (AS), and sperm concentration (CONC)) of Egyptian buffalo bulls and evaluate the importance of some nongenetic factors (year (YC) and season (SC) of semen collection and age of bull genetically and environmentally at collection (ABC)) affecting the investigated traits. A total of 7761 normal semen ejaculates were collected from 26 bulls from 2009 to 2019. Single-trait and bivariate repeatability animal models using Bayesian methods were used to estimate variance components, heritability, repeatability, and genetic correlations among the investigated semen traits. YC and ABC exerted significant effects on most semen traits, whereas SC exerted no significant effect on all the investigated semen traits. Heritability estimates were 0.08, 0.52, 0.51, 0.04, and 0.49 for VOL, MM, LS, AS, and CONC, respectively. Repeatability estimates were 0.14, 0.82, 0.79, 0.06, and 0.78 for VOL, MM, LS, AS, and CONC, respectively. The genetic correlations between MM and each of LS and CONC were highly significant , and that between LS and CONC was also highly significant (0.92 ± 0.20). The high heritability estimates for MM, LS, and CONC combined with the favorable high significant genetic correlations between these traits indicated that direct selection for MM may be an effective method to enhance semen quality in Egyptian buffalo bulls and consequently improve fertility. In dairy cattle, fertility is considered one of the most essential economic characteristics . Using a graduated glass tube, the ejaculate volume was measured directly in milliliters to the nearest 0.1 ml. The percentage of spermatozoa wave motion in a drop of semen deposited on a glass slide was used to calculate semen mass motility (%). The abnormal sperm (%) were measured according to the procedure adopted by Blom (9 spermatozoa/mL) in each ejaculate was determined using a Neubauer hemocytometer. Percentage of livability, motility of spermatozoa, then sperm count was estimated by using a warm microscope stage in post-diluted, post-equilibrated and post-thawed semen adjusted at 37°C. Research microscope with high power magnification (×400) and warmed stage (37°C) was used to estimate the percentage of progressive sperm motility  at Sakha, Kafr El-Sheikh Governorate, belonging to the Animal Production Research Institute, Ministry of Agriculture, Dokki, Cairo, Egypt. According to NRC , the bul by Blom  and BarbAn analysis using the GLM procedure of SAS  was conducted to evaluate the significance of the nongenetic environmental effects of season of semen collection, year of semen collection, and age of the buffalo bull by fitting the following linear model:Yijkl=the observation of the examined trait ; μ = a trait-specific underpinning constant; Si = the fixed effect of the ith season of semen collection ; Tj = the fixed effect of the jth year of semen collection ; Ak = the fixed effect of the kth age of the bull at semen collection , and eijkl is the residual of the model.where A Bayesian approach was used to estimate variance components and population genetic parameters for the investigated semen traits using the THRGIBBS1F90 software  genetic effects was assumed to have a normal distribution with mean 0 and variance Aσ2a, where A is the numerator relationship matrix based on the pedigree, and σ2a is the additive genetic variance. The vector of the permanent environmental effects was assumed to be normally distributed with mean 0 and variance Icσ2pe, where Ic is the identity matrix with the number of buffalo bulls as its order, and σ2pe is the permanent environmental variance. Heritability (h2) was calculated as the ratio of genetic variation due to the additive genetic variance to the total phenotypic variance (r) was calculated by dividing the additive genetic variance plus permanent environmental variance on the total phenotypic variance  effects on MM, LS, and CONC but not on VOL and AS. However, ABC exerted significant (P = 0.0001) effects on VOL, MM, LS, and CONC but not on AS, considering that AS remained significantly unaffected by any one of the nongenetic examined factors. The season of semen collection exerted no significant effect on all the examined semen traits. It is possible that the relevant effect of year of collection on most semen characteristics is due to differences in nutrition, climate, and management procedures across years (Khattab et al., Table The estimates of variance components, heritability, and repeatability for semen traits are given in Table The phenotypic and genetic correlations between any two traits illustrate how a change in one character affects the other. Knowledge of genetic and phenotypic correlations is essential for generating selection indices and the selection for multiple traits. The majority of semen traits examined in this study had desirable genetic correlations with each other. Estimates of the genetic correlation for VOL, MM, LS, AS, and CONC traits ranged from 0.17 to 0.99. However, estimates of the phenotypic correlation between these traits ranged from 0.15 to 0.99 Table . HoweverIn conclusion, the year of semen collection and age of bull at semen collection exerted significant effects on semen traits of Egyptian buffalo bulls. However, the season of semen collection did not exert relevant impact on the examined semen traits. The high heritability estimates for MM, LS, and CONC, as well as the positive high significant genetic correlation between these traits, suggested that direct selection for MM could be an efficient method to increase semen quality in Egyptian buffalo bulls and, thus, improve fertility.