Objectives The present work aimed to evaluate the effect of lemongrass extract incorporated in a resorbable periodontal dressing on gingival wound healing microscopically, following gingivectomy in rats.Materials and Methods Thirty healthy adult male Sprague–Dawley rats were used in this study. Gingivectomy was performed on anterior area of lower jaw in the labial surface of central incisive and, subsequently, wound areas were covered with povidone iodine gel , lemongrass resorbable dressing , and a cellulose-based dressing containing myrrh . Histological changes were monitored in days 4, 7, and 14 postsurgery to evaluate fibroblast and collagen deposition as repair stage of healing process.Statistycal Analysis One-way analysis of variance (ANOVA) followed by Tukey's post hoc for multiple comparisons were employed to measure differences between pairs of means, p-value of 0.05 was considered statistically significant.Results We observed significant difference repair parameters of the healing process between surgical sites treated with lemongrass periodontal dressing and control groups. Wounds treated with lemongrass dressing had greater fibroblast compared with control groups in 4 and 7 days after surgery (p≤ 0.05).Conclusion The results suggest positive potential therapeutic effects for this new formulation of periodontal dressing on acceleration of surgical wound healing that lead to improvement of periodontal treatment consequences following gingivectomy. Oral cavity is a habitat of millions of pathogenic and opportunistic bacteria that are favorable for infections in the presence of any cut or wound in the epithelium. Surgical therapy performed in the oral cavity will result in oral wound, and without controlling the microbial activity, the wound healing delays and the treatment fails.Periodontal pack and periodontal dressing are the terms used for periodontal bandages. To cover and protect wound surfaces, it is used after oral surgery, frequently applied around the necks of the teeth, and adjacent tissue. In earlier days, dressing acts as a protective barrier and has no curative properties. It is suggested to be used, as it helps in reducing discomfort and pain postoperatively by shielding the site of surgery even without any therapeutic effects.One of the surgical therapies frequently performed in dentistry is gingivectomy, defined as surgical removal of the gingiva to the bottom of the pocket.Many attempts have been made to enhance the properties of dressings, that is, incorporating chlorhexidine or antibiotics as antibacterial properties, to improve healing process and prevent infections.Cymbopogon citratus) is a perennial herb belongs toPoacea, generically named as grasses.Among various types of periodontal pack, resorbable dressing offers advantages, since it does not require removal and can be safely degraded itself. It is a soft and soluble dressing that adheres to the wound surface, dissolves in approximately 30 hours and is consisted mostly of cellulose as a base which is a hydrophilic, elastic material with several active agents incorporated.The present study aimed to evaluate the effect of lemongrass wound dressing on the healing process microscopically after gingivectomy in rats.This study evaluated and compared the effects of lemongrass periodontal dressing, povidone iodine gel, and a cellulose-based periodontal dressing with myrrh as active ingredient already available in the market  on wound healing after gingivectomy in rats assessed by fibroblast proliferation and collagen deposition.In this study, 30 male Sprague–Dawley rats, weighing 250 to 350 g were recruited. One week before the experimental procedures, the animals underwent adaptation at air-conditioned animal laboratory room (22 ± 3°C) with 12-hour light and dark cycle. The rats were fed with commercial normal rodent pellet and filtered water ad libitum. All of the animals received humane care according to the criteria outlined in the Guide for the Care and the Use of Laboratory Animals prepared by the National Academy of Science and published by the National Institute of Health.The experimental design and protocols were reviewed and approved by the Ethics Committee of the Experimental Animal Care Society, Biopharmaca Research Centre, Bogor Agriculture Institute, West Java, Indonesia, under file number 004–2017 KEH TROP BRC.Lemongrass was cultivated in Subang, West Java Province, Indonesia at 6° 34' 17.7204'' S 107° 45' 31.4496'' E, 700 m above sea level and collected in September 2016. Plant authentication was performed by a plant taxonomist with collection number BMK0204092016 deposited in Herbarium Bogoriense, Department of Biology, Bogor, West Java, Indonesia.Fresh lemongrass of 5 kg was washed, minced, and dried in an oven for 3 days at 50°C. Dried leaves were then ground to powder. Maceration of lemongrass was performed by soaking powder in 70% ethanol, with a ratio of 1:10 for 3 × 24 hours at room temperature (±27°C) and stirred with a shaker at 150 rpm, then filtered and concentrated by rotary evaporator at a temperature of 50 to 60°C. Ethanol extract obtained was dark green in color and tasted bitter.Dressing was prepared using thick extract of lemongrass, propylene glycol, methyl paraben, prophyl paraben, aquadest, and hydroxypropilmethyl cellulose (HPMC) as gelling agent. HPMC was soaked in hot aquadest (80°C) for a period of 2 hours. The dispersion was then allowed to hydrate and swelled for 15 minutes. Subsequently, methyl paraben and prophyl paraben were dissolved in ethanol and were added to swollen HPMC. Thick extract of lemongrass was then poured into the mixture, and then prophylene glycol was added and stirred until a homogenous gel was achieved. Aquadest was added until the mixture form a gel base.Sample size calculation was performed by using the following formula:r– 1) (t– 1) ≥ 15 ≥ 15(3–1). These groups received treatments as follows:The animals were randomly divided into three experimental groups (Group P (positive control), rats underwent gingivectomy and were given povidone iodine gel 10%.Group L, rats underwent gingivectomy and were given lemongrass periodontal dressing.Group M (positive control), rats underwent gingivectomy and were given a cellulose-based periodontal dressing with myrrh as active agent.The animals were anesthetized with an intraperitoneal injection of ketamine and xyla mixture, then a gingivectomy with external bevel excision was made on anterior area of lower jaw in the labial surface of central incisive, exposing a rectangular area of 5 mm × 3 mm, using a sterile stainless steel surgical blade no 15 , and subsequently gingiva was separated by periosteal elevator. Each group received allocated regimen immediately after the wounding procedures by researcher's assistant. The animals were sacrificed with euthanasia and exsanguination, three rats for each stage of assessments, that is, at days 4, 7, and 14 after gingivectomy.Tissue specimen were excised and immersed at days 4, 7, and 14 after gingivectomy in alcohol  and cleared three times in xylol, for 1 hour for each cycle. Paraffin was infiltrated to the specimen in three cycles, each cycle was performed for 1 hour. Specimens were embedded in liquid paraffin, blocked and sectioned with 5 μm using a microtome. These sections were then stained with hematoxylin and eosin (H&E) for fibroblast assessment, while Masson's trichrome staining was employed to reveal collagen deposition, then mounted with cover glass and glued with Entellan. The stained samples were viewed under electron microscope (Nikon Eclipse 80i) at ×40 magnification in five fields of view.p-value of ≤0.05 was considered statistically significant.All data were subjected to statistical analysis using SPSS 20.0 . To test the normality of the data, Shapiro–Wilk test was employed, and all data were normally distributed. All values were represented as means ± standard deviation (SD) and were analyzed using one-way analysis of variance (ANOVA) followed by Tukey's post hoc for multiple comparisons to measure specific differences between pairs of means. AAll 30 rats survived the surgical procedures with no complications. Findings on each group were evaluated and histological differences were compared between control and experimental groups of section.p≤ 0.05;The growth of fibroblasts and collagen deposition were calculated in days 4, 7, and 14 after gingivectomy. On day 4 following gingivectomy, the comparison of the histological findings demonstrated that in the group L, fibroblast activity was better expressed than in groups M and P (p < 0.00). The number of fibroblasts in group P was fewer, whereas in group M was moderate and group L had the greatest  being released into solution from the PVP-I complex, penetrating the cell wall, and inactivating cells by forming complexes with amino acids and unsaturated fatty acids, resulting in impaired protein synthesis, and alteration of cell membranes.Periodontal dressing is placed to protect oral wound against mechanical injuries during mastication and against bacterial invasion into the tissue, with the aim to decrease pain and facilitate healing, without any adverse effects such as increase formation of bacterial plaque, bacterial resistance, cytotoxicity, delayed wound healing, or disturbed occlusion. Furthermore, the ease of use is also one consideration of choice. Cellulose-based periodontal pack is soft and unlike conventional periodontal dressings, it remains elastic at all times, it needs no mixing in preparation and slowly gets dissolved over a period of 2 to 3 days, hence no removal is needed. It is suggested that incorporating lemongrass extract in a cellulose-based matrix, may enhance the biological properties of this resorbable pack.Curcuma longarhizome extract and zinc oxide–eugenol (ZOE) dressing on angiogenesis, compared with ZOE dressing alone. The addition ofC. longarhizome extract showed added value in the wound healing process in term of the number of neovascular.Several studies had evaluated the effect of herbal active compounds incorporated in wound dressing. Faiga et al studied the effect of a mixture ofWithin the wound healing process, the inflammatory phase involves homeostasis and inflammation that start at the moment of injury and continue for up to 4 to 6 days. The proliferation phase involves epithelialization, angiogenesis, granulation tissue formation, and collagen deposition, and takes place from days 4 to 14 after injury. Epithelial-cell migration starts after 24 hours.Moringa oleiferaLam leaves extract incorporated in a cellulose-based wound dressing on wound healing in palatal rats, but the applications of the dressing were more frequent (once a day in 14 days) which clinicians or patients were not in favor of that.We had also observed a beneficial effects ofin vitrostudy showed that lemongrass indeed possess antimicrobial activity against several oral pathogens. Rêgo et al investigated that essential oil of lemongrass was effective in controlling bacterial growth in biofilms ofStreptococcus mutans, the main causative agent of tooth decay.Aggregatibacter actinomycetemcomitans,Actinomyces naeslundii, andPorphyromonas gingivalis, as well as the tetracycline-resistant strains. The results showed the superior properties of the essential oil and suggested the use of the oil with other antibiotics against resistant bacteria.Lemongrass has already known for its beneficial effects in oral health. As a folk medicine, based on empirical studies, it is commonly used as remedies for gum swelling, periodontitis (inflammation of tooth supporting tissue), and tooth ache by removing bacteria from the oral cavity.Another beneficial effect of lemongrass essential oil is its anti-inflammatory, as well as antifungal, properties. The exact mechanism of the anti-inflammatory effect of lemongrass is unclear. However, it has been suggested that several molecules contribute to the partial inhibition of the release of inflammation mediator substances.In conclusions, within the limitations of the present study, the following inferences can be drawn: (1) lemongrass extract incorporated in resorbable periodontal dressing was able to stimulate fibroblast and collagen deposition during the initial phase of wound healing after gingivectomy in rats, and (2) one-time application of lemongrass pack immediately after gingivectomy was sufficient to protect wound site and accelerate healing. However, further studies are required to clarify the optimal concentration and physical stability before its clinical application.


Microfluidic technology was recognized in the 1980s when the first micropumps and micro-valves were developed to manipulate fluids for biological applications . Given tPharmaceuticals, “Microfluidic Formulation for Biomedical Applications”, aims to provide a foundation and advancement of microfluidic technology in the biomedical field. The original research and comprehensive review papers in this Special Issue have explored and updated the new progress designs and applied microfluidics in drug development, bacterial identification, real-time assessment of protein, and cocrystal engineering  was used to design the microfluidic devices, which were then developed by Anycubic® Photon Mono X SLA printer with a photocurable resin polymerized at 405 nm. The microfluidic devices with a length of 8.2 cm, width of 3.5 cm, and height of 0.7 cm were printed. These devices contain channels with a diameter of 1 mm and average surface roughness of 0.156 ± 0.106 µm were utilized to control the nucleation rate and cocrystal behaviors of SDM:4ASA. This work proposed for the first time coupling microfluidic devices with a fluidized bed for continuous manufacturing of cocrystallization. Interestingly, 0.1 PVP K25 was proved to avoid crystal formation in microfluidic devices during fabrication processes, resulting in more homogenous particles formed. The SDM:4ASA cocrystals were successfully achieved via integrated microfluidic devices with better morphology and distribution of formed sphere particles than the solvent evaporation method.Cocrystallization has been considered an effective method to alter the physicochemical properties of active ingredients in pharmaceutical drugs. The cocrystals can be created through various processes, including grinding (neat or dry and solvent-assisted grinding), slurry conversion, antisolvent addition, and solvent evaporation ,15. ObtaThe findings of the papers presented in this Special Issue rapidly contribute to exploring and expanding new applications of microfluidic technology in biomedicine. We hope the published original research articles and comprehensive reviews will be attentive and appeal to a broad readership of biology, chemistry, pharmacology, and materials science.


Carica chilensis) is the papaya species with the southernmost distribution within the Caricaceae, thriving in the most extreme environmental conditions. This threatened plant exhibits low natural regeneration, primarily attributed to low germination, yet no information regarding seed dormancy release is available. In this study, we investigated the dormancy-break and germination requirements of C. chilensis. We hypothesized that if C. chilensis seeds exhibit physiological dormancy, then seeds with reduced moisture content and those treated with chemicals or growth hormones would exhibit higher germination percentages and faster germination than control seeds akin to other members of Caricacea. Our results confirmed this prediction and revealed that ultra-drying (< 3% moisture content) and treating seeds with sulfuric acid, gibberellic acid, or potassium nitrate are the most effective methods for germinating C. chilensis. Consequently, we suggest using these treatments to propagate this threatened papaya species.Seed dormancy is one of the most important adaptive mechanisms in plants, optimizing germination, seedling emergence, and establishment to ensure these processes occur when environmental conditions are favorable for plant survival and growth. Endemic to rocky environments of the southern Atacama Desert, the Austral papaya ( However, the successful establishment of seedlings depends on the timing of seed germination; consequently, seeds must possess strategies to perceive their surrounding environment and trigger germination2. Seed dormancy is a plant strategy that optimizes germination, seedling emergence, and establishment so that these processes occur when environmental conditions are favorable for plant survival and growth4. It refers to inhibited germination in mature seeds even under favorable environmental conditions for germination5. Seed dormancy can be particularly important for plants in harsh and highly unpredictable environments , where windows for recruitment are few and sparse; hence, it is more prevalent in these environments than in those with more benign conditions6.Plants rely on seeds for reproduction, genetic continuity, and colonization5: (1) morphological dormancy (MD), where a seed is immature when the fruit falls and requires a period of growth and embryo differentiation for germination to occur; (2) physical dormancy (PY), where the seed coat is impermeable and prevents water from entering the seed, thus requiring mechanical or chemical scarification for germination to occur; (3) physiological dormancy (PD), where a physiological inhibiting mechanism in the embryo results in low growth potential, which prevents the emergence of the radicle through covering layers, hence seeds require a specific set of conditions  to initiate germination; (4) morphophysiological dormancy (MPD), in which an underdeveloped embryo has physiological dormancy, and (5) combinational dormancy, where multiple mechanisms, including physiological, morphological and ecological factors, as well as environmental triggers prevent germination. Most families of plants have seeds with PD3, and depending on the strength of the physiological inhibitory mechanism, they can exhibit one of three levels of PD: (1) non-deep , warm or cold stratification, after-ripening in dry storage, and mechanical or chemical scarification), (2) intermediate , or (3) deep 9.Seed dormancy is classified into five general classesCarica chilensis (Planch. ex A.DC.) Solms., commonly known as the Austral Papaya, is an endemic papaya species of Chile distributed along the southern limit of the Atacama Desert12. This species belongs to the Caricaceae, a predominantly tropical plant family that includes the common papaya (Carica papaya). The family comprises 35 species distributed across six genera13, most with seed dormancy3. Despite the economic importance of the Caricaceae, studies regarding its germination requirements are scarce, primarily focusing on C. papaya16 or a few Vasconcella species18. Results from these studies suggest that seeds of this plant family exhibit PD3 and that low seed germination is due to inhibitory substances, mainly phenolic compounds21, present in both the sarcotesta (the gel-like coating around the seeds) and the sclerotesta 17. However, further research is needed to ascertain the kinds of dormancy in Caricaceae, aiming to enhance our comprehension of the factors influencing germination in this family.C. chilensis seeds exhibit PD, then seeds with reduced moisture content (MC) and those treated with chemicals or growth hormones would exhibit higher germination percentages and faster germination than control seeds akin to other members of Caricacea7. Understanding the mechanisms and factors that govern seed germination and dormancy in C. chilensis holds great importance for several reasons. Firstly, the presence of papain in its fruit makes this wild papaya a plant of interest for cultivation22. Secondly, C. chilensis is classified as Vulnerable due to its limited presence in a few fragmented, low-density populations, and to the decline of natural populations resulting from habitat destruction22. Thus, studies examining its propagation have been recommended as a conservation strategy23. Lastly, the lack of knowledge regarding germination requirements of most native non-tree species in Chile is considered one of the major bottlenecks for fulfilling the country’s restoration commitements24. Therefore, there is an urgent need for studies assessing the dormancy-break requirements of these species.This study aimed to investigate the seed dormancy-break and germination requirements of the Austral papaya, the southernmost species of the Caricaceae. We hypothesized that if C. chilensis seeds was 33.5% ± 0.98 (mean ± sd). Most essays successfully released seed dormancy; however, the germination percentage remained generally low, varying between 0 and 10% in the pre-sowing treatments for fresh seeds and from 0 to 40% for ultra-dry seeds  increased germination by 200%, while both gibberellic acid (GA3) and potassium nitrate (KNO3) enhanced it by 176%  levels and increasing gibberellins (GA)33. These two hormones regulate seed germination in opposite manners: ABA promotes seed dormancy and inhibition of germination, whereas GA promotes germination34.Germination was 77% higher in ultra-dry than in fresh seeds. Similar to our results, ultra-drying promoted germination in C. chilensis because the species produces mature fruits between August and October, prior to the onset of summer. Since both temperature and the gradual loss of MC are integrated over time to alter the depth of the dormancy2, the hot and dry conditions of the Mediterranean summer in central Chile likely contribute to the gradual release of dormancy throughout the season. Consequently, seeds can germinate in the field at the onset of the winter rain pulses35 and take advantage of the moist soils and warmer temperatures during the spring to promote seedling establishment. Nonetheless, given that germination patterns and seed dormancy can vary geographically36 and that we collected seeds from a population located towards the southern end of C. chilensis’ distribution, which has drier and warmer summers, it will be informative to confirm if seeds from other localities show similar behavior.A reduction in seed MC is likely to occur naturally in C. chilensis seeds with H2SO4, GA3, or KNO3. The seed coat of Caricaceae is multiplicative, consisting of a fleshy outer layer known as the sarcotesta, enclosing a hard, lignified portion of the testa37. Hence, scarification with H2SO4 can enhance water absorption and uptake, essential for initiating germination, by breaking down the seed coat. Gibberellins are a family of plant hormones that control many aspects of plant growth, including germination2. GA3 stimulates germination through several mechanisms, including producing hydrolytic enzymes that weaken the seed coat38, mobilization of nutrient reserves, and stimulation of plant embryo expansion and hypocotyl elongation39. Numerous studies have documented enhanced germination in C. papaya with the application of GA340. Similarly, GA3 promotes germination in a few species of Vasconcellea8. However, apart from these findings, there is currently a lack of information regarding the effects of GA3 in other Caricaceae species. Finally, KNO3 can break seed dormancy and promote germination in at least two ways. First, it has hygroscopic properties; when seeds are imbibed in a KNO3 solution, they absorb moisture from the surrounding environment, weakening the seed coat. Second, it inhibits ABA synthesis while stimulating the synthesis of GA, which promotes germination by enhancing the growth potential of the embryo and overcoming the mechanical barriers imposed by the testa2.Dormancy was released by treating 41. Thus, improving our understanding of seed biology is crucial to restoring a broader and more representative range of species42. Chile is one of 115 countries that has subscribed to restoration commitments43. However, dormancy-break and germination requirements of seeds of most non-tree species in Chile remain poorly known. This lack of knowledge hinders the propagation of threatened plants and is recognized as a bottleneck for fulfilling Chile’s restoration commitments33. This study contributes to filling this gap with the aim of promoting more extensive use of species diversity in ecological restoration and helping to conserve endangered plant species.One of the major impediments to the potential use of wild species germplasm for habitat restoration is the need for more knowledge about techniques for breaking seed dormancy and caring for germinating seedsCarica chilensis is an endemic shrub of northern Chile distributed along the southern limit of the Atacama Desert, between the Atacama  and Valparaiso  Regions. It is classified as threatened, and due to its slow growth and low germination percentages, C. chilensis experiences minimal natural regeneration. Like most Caricaeae13, this species is polygamous with male, female, and hermaphrodite plants. It produces mature fruits from July to October, with peak fruiting in September. Each fruit contains an average of six seeds enveloped by a gelatinous layer. As the southernmost species in the family, C. chilensis is subject to extreme environmental conditions, such as drought and saline soils, across its distribution range.C. chilensis fruits from 40 individuals in the Pupío basin in North Central Chile  between July and September 2021. The area has a Mediterranean climate with warm, dry summers and cool, wet winters44. The mean annual temperature is ~ 22 °C; July is the coldest month , and February is the warmest . Mean annual precipitation is 227 mm, 86% of which falls from May to August .We collected mature We collected between five and eight fruits per plant and placed them in paper bags in a cooler until they were processed a maximum of two days later in the laboratory at Universidad de La Serena. We manually removed the seeds from the fruits and cleaned them with a toothbrush under running water to remove the sarcotesta. Then, we pooled the seeds together for the experiments.C. chilensis seeds by examining the combined effects of MC and pre-sowing treatments. To establish the MC treatment, we first assessed initial seed MC by weighing 100 seeds before and after drying at 130 °C for three h45. Seeds for the ultra-dry treatment were then placed in Eppendorf tubes with blue silica gel and dried to < 3% of their initial MC. We assessed germination of fresh and ultra-dry seeds in each of nine pre-sowing treatments: (1) Control (no pre-sowing treatment); (2) seeds soaked in a 400 ppm solution of gibberellic acid (GA3) for 24 h at room temperature; (3) seeds soaked in a 1 M solution of potassium nitrate (KNO3) for 30 min; (4) seeds soaked in distilled water changed daily for seven days at room temperature (hydro conditioning); (5) seeds soaked first in distilled water for 24 h and then in hot water (35 °C) for four h (Temperature shock); (6) seeds shaken in a glass jar for 10 min (percussion), (7) seeds cold (moist) stratified, kept at 5 °C for 7 days; (8) seeds soaked in a 100% solution of hydrogen peroxide (H2O2) for 20 min and; (9) seeds soaked in a 10% solution of sulfuric acid (H2SO4) for 30 min.We determined the dormancy-break requirements of ca. 12 ml of water). Petri dishes were incubated in germination chambers with 16 h of light at 25 °C7, and we monitored germination periodically for 94 days. We considered a seed germinated when the radicle emerged (> 2 mm). At the end of the experiment, we calculated the number of germinated seeds, and the seed germination percentage and rate for each Petri dish.We replicated each treatment combination in 10 Petri dishes and sowed each dish with ten seeds in sterilized sand (60 g), which was hydrated to carrying capacity (46) nested within each Petri dish to consider the non-independence of seeds. In these models, the dependent variable is a hazard function, which represents how the instantaneous “risk” of experiencing the event  changes with time. This risk function was compared to a "baseline hazard function," representing the risk of the event occurring at a specific time in a reference individual or group47. To establish a baseline, we utilized the germination rates of fresh and control seeds as the baseline hazard because this is the natural state of the seeds. By comparing the hazard ratios, we could identify the conditions promoting the fastest germination. Subsequently, we investigated how the combined effects of MC and pre-sowing treatments affect the overall number of seeds germinating using a Generalized Linear Model. In this model, the independent variables were MC and pre-sowing treatment, and the dependent variable was the number of germinated seeds per Petri dish . We performed all statistical analyses using the R statistical environment48.Initially, we evaluated the independent effects of MC and pre-sowing treatments on seed germination using a Cox Proportional hazards model (‘survival’ packageC. chilensis is Chile’s sole wild Caricacea species in Chile and easily identifiable in the field, there was no need to collect voucher specimens.Plant material collection was carried out per relevant institutional, national, and international guidelines and legislation, including the IUCN Policy Statement on Research Involving Species at Risk of Extinction and the Convention on the Trade in Endangered Species of Wild Fauna and Flora. Seeds were obtained from plants on private lands, and we obtained permission from the landowners to access the areas and collect the seeds. Given that Supplementary Information.


Background: The risk of falls and bone fractures with sodium-glucose co-transporter-2 (SGLT2) inhibitors has been characterized by conflicting evidence. Therefore, we decided to investigate the reporting probability of falls and fractures by comparing SGLT2 inhibitors with DPP4 inhibitors.Methods A retrospective, pharmacovigilance study of the European database of Individual Case Safety Reports (ICSRs) was conducted. Disproportionality analyses  were conducted to compare the reporting probability of falls or fracture between treatments.Results A total of 507 ICSRs reporting at least one fall or fracture with SGLT2 inhibitors were identified. The most reported SGLT2 inhibitor was canagliflozin , followed by empagliflozin , and dapagliflozin . A total of 653 events related to fall or bone fracture were reported. Fall was the most reported event . Among fractures , the most reported were foot fractures  and hip fractures . SGLT2 inhibitors were associated with a lower reporting probability of fall than DPP4 inhibitors . The lower reporting probability of fall was also observed when the single SGLT2 inhibitor was compared to DPP4 inhibitors: dapagliflozin , canagliflozin , and empagliflozin . For fractures, canagliflozin showed a slightly significant increased reporting when compared with DPP4 inhibitors , whereas all other comparison showed no statistically significant difference.Conclusion SGLT2 inhibitors were associated with a lower reporting probability of fall than DPP4 inhibitors, in accordance with the reassuring evidence about the safety profile of these drugs. Future researches will help to confirm their long-term safety profile. Sodium-glucose co-transporter-2 (SGLT2) inhibitors were firstly authorized for the treatment of type 2 diabetes mellitus, but subsequently dapagliflozin and empagliflozin also for the treatment of heart failure with reduced ejection fraction based on their favorable cardiovascular outcomes . Indeed,Despite their clinical benefits, these drugs have also been associated with safety concerns in different cardiovascular trials, some of which have already been implemented in the summary of product’s information by Regulatory Agencies . Among sA retrospective, European, pharmacovigilance study aiming to compare the reporting probability of falls or bone fractures between SGLT2 inhibitors and DPP4 inhibitors.The EV was used to retrieve ICSRs from 1 January 2015 to 31 December 2022 for both SGLT2 and DPP4 inhibitors. Considering the different dates of marketing authorization, the study start date was chosen to make the post-authorization years equal among SGLT2 inhibitors and DPP4 inhibitors. Only ertugliflozin was authorized in Europe after the study start date (21 March 2018); therefore, it was excluded from analyses.www.adrreports.eu.The EV is a database of European Medicines Agency (EMA) intended for the collection, management, and analysis of ICSRs related to medicines or vaccines authorized or under investigation in clinical trials in the European Economic Area (EEA). Healthcare professionals (HCP) or non-HCPs can spontaneously report an ICSR to a marketing authorization holder or an EU national competent authority, which are then responsible for their registration in EV. Data contained in EV are available at ICSRs with SGLT2 inhibitors  or DPP4 inhibitors  as suspected drugs were selected by using the line listing function of EV. DPP4 inhibitors were chosen as the comparator because they are oral drugs frequently used as second-line therapy for type 2 diabetes mellitus. Moreover, they seem to be neutral on the risk of falls and bone fractures . Selectivice versa, and considering that in the spontaneous reporting it can be reported only one of these events due to quality biases, we also assess the reporting probability of bone fractures  of SGLT2 inhibitors compared to DPP4 inhibitors.The primary study endpoint was the reporting probability of fall of SGLT2 inhibitors compared to DPP4 inhibitors. Secondarily, since sometimes bone fractures can be associated with falls or For descriptive purposes, the following information from ICSRs with SGLT2 inhibitors or DPP4 inhibitors as suspected drugs were retrieved: patient’s characteristics (age group and sex), type of reporter (HCP or non-HCP), primary Source Country for regulatory purposes (EEA or non-EEA), number of reported suspected drugs, and concomitant drugs. Considering that SGLT2 inhibitors can be used to treat two different diseases (diabetes mellitus and heart failure), we tabled their therapeutic indications as High-Level Group Term (HLGT) of the MedDRA. Events of fall and fracture related to SGLT2 inhibitors were tabled for suspected drugs and described in terms of type of event, outcome, and seriousness. According to the International Council on Harmonization E2D guidelines, an event was classified as serious if it met the following criteria: results in death, hospitalization or its prolongation, severe or permanent disability, congenital abnormalities/birth defects, life-threatening, or a clinically relevant condition. The outcome of the event was classified into: “recovered/resolved”, “recovering/resolving”, “recovered/resolved with sequelae”, “not recovered/not resolved”, “fatal”, or “unknown”. The median time to onset (TTO) of fall and fractures and its interquartile range (IQR), expressed in days, were also computed when the information on the duration of therapy and drug discontinuation as action taken was available in the ICSR.To assess cardiovascular risk factors for fall, ICSRs were also described for the presence among therapeutic indications (where available) of other suspected or concomitant drugs of atrial fibrillation, hypotension, dizziness, or hypoglycemia; or the presence among other suspected or concomitant drugs of cardiovascular treatments .The Reporting Odds Ratio (ROR), its 95% Confidence interval (95%CI), and the chi-square test were computed to compare the reporting probability of fall and fractures between SGLT2 inhibitors and DPP4 inhibitors. The ROR was calculated as (a/c)/(b/d): “a” is the number fall or fractures reported with the SGLT2 inhibitor, “c” the number of fall or fractures with the comparator (DPP4 inhibitors), “b” the number of other events reported with the SGLT2 inhibitor, and “d” the number of other events reported with comparator. This analysis was also computed to evaluate the reporting probability of fall and fractures between SGLT2 inhibitors and DPP4 inhibitors in only male or female, and in only cases aged ≥65 years or <65 years. Moreover, this analysis was performed to assess the reporting probability of both events comparing sex  and age (≥65 years vs. < 65 years) within the class of SGLT2 inhibitors. To evaluate the impact of cardiovascular risk factors on the reporting probability of fall, a sensitivity analysis was performed by comparing cases without predisposing risk factors to cases with risk factors for each SGLT2 inhibitor. Finally, considering that an ICSR could report both treatments (SGLT2 inhibitors and DPP4 inhibitors), we performed a sensitivity analysis by excluding such ICSRs. All analyses were performed only for events reported at least 3 times for each drug. A 5% significance level was considered for all analyses. RORs were displayed with forest plots. Data management and analyses were performed with R .During the study period, a total of 507 ICSRs reported at least one event of fall or fractures with SGLT2 inhibitors. The most reported SGLT2 inhibitor was canagliflozin , followed by empagliflozin , and dapagliflozin . Only 1 (0.2%) ICSR reported the combination of two SGLT2 inhibitors (dapagliflozin and empagliflozin) and it was excluded from the analyses due to the low number. Most ICSRs were related to patients aged 65–85 years  and mainly reported in females . Most ICSRs were reported by HCPs , and came from the non-EEA . The SGLT2 inhibitor was the only suspected drug reported  and no concomitant drug  was reported in most ICSRs. A total of 362 ICSRs reported at least one event of fall and fractures, with sitagliptin as the most reported DPP4 inhibitors , followed by linagliptin , vildagliptin , saxagliptin , and alogliptin . Only two ICSRs (0.5%) reported both sitagliptin and saxagliptin as suspected drugs. Characteristics of ICSRs for each SGLT2 inhibitor and for DPP4 inhibitors were reported in n = 116), vertigo (n = 47), hypotension (n = 40), hypoglycemia (n = 16), atrial fibrillation (n = 5), and diabetic coma (n = 4). Cardiovascular medicines identified were beta-blockers, angiotensin receptor blockers, ACE inhibitors, antiplatelet, anticoagulants, diuretics, and alfa1-blockers. Overall, events of bone fractures with SGLT2 inhibitors were 320 (49.0%), with foot fractures  and hip fractures  as the most reported. Fall or factures events reported with each SGLT2 inhibitor are listed in A total of 2,542 events were identified among ICSRs (N = 507), with a mean of 5.0 events per ICSR. All events are showed in SGLT2 inhibitors were associated with a lower reporting probability of fall than DPP4 inhibitors . The lower reporting probability of fall was also observed in the analysis with the single SGLT2 inhibitor: dapagliflozin , canagliflozin , and empagliflozin  compared to DPP4 inhibitors . A lowerp-value, <0.001) and fractures . Moreover, the age ≥65 years was associated with a higher reporting probability of fall  and fractures  than <65 years.In the analyses within the class of SGLT2 inhibitors, female were associated with a higher reporting probability than male for both fall , canagliflozin , and empagliflozin . All results of sensitivity analyses are shown in Despite limitation of our analyses performed on pool spontaneous reports of adverse events, in this real-world safety pharmacovigilance study, we found a 34% lower reporting probability of fall with SGLT-2 inhibitors compared with DPP4 inhibitors. Specifically, a 44% lower reporting probability of fall was found for canagliflozin, followed by dapagliflozin (33%), and empagliflozin (23%) in spite of the different year of marketing authorization. Indeed, dapagliflozin was the first authorized SGLT-2 inhibitor (Year 2012) in Europe, followed by canagliflozin (Year 2013) and empagliflozin (Year 2014). Although European consumption data on SGLT2 inhibitors are lacking, canagliflozin seems the most prescribed SGLT-2 inhibitor followed by empagliflozin and dapagliflozin .In Europe, falls are related to at least 3.8 million/year of visits in the emergency departments for fall-related injuries in older adults, of which 1.4 million generally require hospitalization . Falls nAlthough there are biologically plausible mechanisms underlying the onset of these adverse events with SGLT-2 inhibitors, we found a lower reporting probability of falls and no effect on the reporting probability of fractures  when these drugs were compared with DPP4 inhibitors. Clinical studies on this outcomes are inconsistent. The CANVAS trial found a higher rate of fractures (26%) with canagliflozin than placebo  Hazard . MoreoveIn the analysis for gender, we found a higher reporting probability with female than male in accordance with the CANVAS and an observational study that found a high rate of fractures in female but not associated with a statistically significant increased risk . Furtherwww.adrreports.eu), making impossible the computation of disproportionality analyses on all ICSRs. Furthermore, the exact denominator of patients exposed to SGLT2 inhibitors cannot be evaluated in EV, not allowing any estimate in terms of incidence. The total number of events for a drug can be used instead as a denominator for disproportionality analyses. Finally, in the absence of consumption and prescription data, we cannot exclude that differences in the reporting were related to a differential use.The main strength is the use of the large EV database that allows to detect a wide range of real-life safety cases related to the treatment with SGLT2 inhibitors. The use of pharmacovigilance data is indeed not expensive and helpful to better characterize the drug safety profile. However, several limits need to be identified for the analysis of EV data. Firstly, safety reports may not be reported to national competent authorities and therefore in EV (underreporting), thus implying that not all safety cases that occurred in real-life are contained in EV. There are several reasons for failing to recognize an adverse events as linked to a drug. The common reasons for HCPs are the feeling of guilt, ignorance, lethargy, inadequate risk perception, diffidence, insufficient training, and lack of awareness about pharmacovigilance . AnotherIn this European safety study, SGLT-2 inhibitors were associated with a lower reporting probability of falls compared with DPP4 inhibitors. Results were consistent across sex and age categories. Our results provide real-world evidence on the safety profile of SGLT-2 inhibitors. Generally, prior to initiate any treatment, clinicians must consider predisposing risk factors for potential adverse events before developing or adjusting a treatment pharmacological plan that includes SGLT2 inhibitors. Future researches and post-marketing analyses involving these drugs will help to understand their long-term safety.


When psychological hardiness is low, the level of perceived stress has a statistically significant moderating effect, i.e., it reduces the effect of hardiness on performance. When comparing the effects of perceived stress and psychological resilience, the latter has a stronger moderating effect on performance. Specifically, the moderating effect of resilience was more evident in Model 2  for the military performance of the reservists than the perceived stress in Model 1 . This means that resilience increases the accountability of Model 2 compared to Model 1 by 14.4%. We conclude that resilience training could statistically significantly increase the military performance of reserve soldiers as a tactical population. The purpose of this study is to evaluate the effect of hardiness on the perceived military performance of reservists, i.e., young people who have full-time jobs in a civilian sector and perform military training as a part of their civic duty. We proposed the conceptual model with conditional indirect effects of the hardiness on personal military performance, where mediated moderation effects are observed from personality traits and variables important for military service: team cohesion, perceived stress, and psychological resilience. The final dataset was comprised of 384 self-reported paper–pencil questionnaires filled out by reserve soldiers, and PROCESS Macro 3.5 Model 7 and Model 14 were used for the analysis. The results revealed that perceived stress (Model 1) and psychological resilience (Model 2) have a statistically significant moderate mediating effect on the interlink between hardiness and performance when personality traits and team cohesion are taken into consideration. The change in R Most European countries are strengthening their military personnel by enlisting reservists on a voluntary and mandatory basis to increase the capability of their tactical population. Military reservists are young people who have full-time jobs in a civilian sector and perform military duties and military training on demand as part of their civil obligations. The transition from civilian life to military life and back again is iterative , so reseHardiness is perceived as a psychological skill that gives positive effects after experiencing stress . HardineRecently, the reservist service has attracted the attention of researchers as a unique environment where, on the one hand, there are many stressors ,10,11, aFurthermore, it should be mentioned that the military environment is unique in terms of team compositions and team cohesion as a form of psychological support in a stressful environment. Group cohesion in military training has been shown to increase resilience to stress ,23 and rDespite extensive research carried out on hardiness in the military, the complexity of the hardiness–performance interrelationship among military reservists has not yet been elucidated. There is a lack of research that assesses this interrelationship, considering the effects of other individual and group characteristics, not only the direct effects of hardiness on military performance. This is an important research gap, taking into consideration that reservists are highly diverse in terms of their life experience that comes from their everyday civil life. Accordingly, with this study, our aim was to extend these findings by including other individual and group characteristics to better understand the complexity of the hardiness–performance interrelationship. We studied this interrelationship in a sample of Lithuanian Active Army Personnel Reserve (AAPR) soldiers after they completed a five-week reserve training course. In this paper, we test two models of the hardiness–performance interrelationship. Model 1 provides evidence on how perceived stress as a moderator affects the relationship between individual and group variables in military performance. As individual variables, personality traits were used in this research. The group variables were measured using group cohesion. Both group cohesion and personality traits, as indicators of small-group or individual behavior strategies, are expected to have a mediating effect on the hardiness–performance interrelationship. Model 2 explores the moderating effect of psychological resilience on the relationships mentioned above.The purpose of this research is to evaluate the effect of hardiness on the perceived military performance of reservists, i.e., young people who have full-time jobs in a civilian sector and perform military training as a part of their civic duty. Our results have significant practical implications. They suggest that a certain level of hardiness, which is a stable personality characteristic over time, can effectively buffer the negative impact of perceived stress on military performance. Additionally, our findings provide evidence regarding the level of psychological resilience that should be developed during military exercises to enhance positive military performance. The rest of the paper is organized as follows: The military environment is perceived to be more stressful than the civilian one ,8; thereRecent work on military performance indicates that psychological hardiness has a positive effect on the performance of recruits. Following Bartone & Bowles’  researchThe other psychological construct and determinant of military performance is psychological resilience. Resilience is described as the individual capacity to adapt and cope with adverse or unpleasant experiences . ResiliePrevious works focused on military training paid some attention to the personality traits of the soldiers. The researchers concluded that different types of personalities lead to different levels of perceived level of stress during military training . It seemIn addition, numerous studies have confirmed the positive effects of team cohesion on individual performance in stressful situations in general ,40 and iFrom an operational perspective, military effectiveness is understood as the interaction of the individual soldier with the system of assigned material resources . On the The perceived military performance of reservists is a strong motivator to continue military service and stay active and engaged during military training . PerceivTaking these theoretical insights together, we constructed two conceptual models of influence that specify both individual and combined influences see . Using mFollowing the methodological recommendations, the mediators explain the possible relationship between two variables, and are possible explanations for a relationship between the independent variable (IV: hardiness) and the dependent variable (DV: performance) . In our Hypothesis H1.Reserve solders’ five personality traits and their team cohesion will mediate the relationships between hardiness and perceived military performance.We tested this hypothesis by using a sub-hypothesis for each indicator: the mediating effect of conscientiousness was tested using Hypothesis H1a, emotional stability using Hypothesis H1b, extraversion using Hypothesis H1c, agreeableness using Hypothesis H1d, openness to experiences using Hypothesis H1e, and team cohesion using Hypothesis H1f. The detailed information is provided in Following the methodological recommendations, the moderators affect the magnitude of the effect of the independent variable (hardiness) on the dependent variable (performance) . FollowiHypothesis H2.Perceived stress will play a moderating role in the relationship between hardiness and reserve soldiers’ personality traits and their team cohesion.We tested this hypothesis by using sub-hypotheses for each indicator: the moderating effect on conscientiousness was tested using Hypothesis H2a, emotional stability using Hypothesis H2b, extraversion using Hypothesis H2c, agreeableness using Hypothesis H2d, openness to experiences using Hypothesis H2e, and team cohesion using Hypothesis H2f. The detailed information is provided in Hypothesis H3.Perceived stress will have a moderating effect on the mediating role of reserve soldiers’ personality traits and team cohesion.Similarly to the previous hypothesis, we tested this hypothesis using sub-hypotheses H3a–H3f. The detailed information is provided in Hypothesis H4.Psychological resilience will play a moderating role in the relationship between perceived performance and reserve soldiers’ personality traits and team cohesion.Accordingly, we developed sub-hypotheses H4a–H4f. The detailed information is provided in Hypothesis H5.Psychological resilience has a moderating effect on the mediating role of reserve soldiers’ personality traits and team cohesion.Accordingly, we developed sub-hypotheses H5a–H5f. The detailed information is provided in Following these hypotheses, we constructed two research models see . HypotheWe used simple random sampling and delivered 400 questionnaires to randomly selected Active Army Personnel Reserve (AAPR) soldiers who had been called up for a 5-week reserve training course, which began in January and ended in February 2022. There were 390 completed paper–pencil questionnaires (97.5% response rate). The check for quality and missing value analysis showed that there were 4% missing data in the collected questionnaires, so these questionnaires were removed from the data sample. The 384 questionnaires were the final dataset that was used for this investigation. The survey was carried out with men (100%). The demographic background of the reservists was provided by self-reported information. The age of the reserve soldiers ranged from 20 to 47 years, the average was 29.5 years (±SD = 4918), and most (81.7%) represented men with an age between 24 and 32 years. The education level of the soldiers in our study ranged from secondary education to a master’s degree. The surveyed soldiers were mainly single (69%). Additional demographic information is presented in The study was approved by the General Jonas Zemaitis Military Academy, Protocol No. PR-1815. Each participant was provided with information about the study; their voluntary participation and anonymity were ensured. General and military-specific research instruments were used to measure the research variables. The instruments included measurements for five independent variables—psychological hardiness, perceived stress, personality traits, team cohesion, and psychological resilience—and one dependent variable, perceived military performance of the reservists. The instrument was composed of five scales.Military Hardiness Scale. Psychological hardiness was measured as the degree to which reservists are committed, feel challenged, and have a sense of control over their work experiences in the military environment. Hardiness was measured by the 11-item Military Hardiness Scale . The itePerceived Stress Scale. The level of perceived stress of the reserve soldiers was measured using a standardized Perceived Stress Scale ,55. OrigBig Five scale. Personality traits were measured using the Big Five scale of ten items, known as the five-factor model . This peTeam Learning Behavior Scale. The cohesion of the team of reserve soldiers was measured using the Team Learning Behavior Scale of 8 items , developPerceived Military Performance Scale. We employed a perceived military performance scale to assess the soldiers’ performance across various areas during their military training, such as tactical field exercises, defensive operations, and defense in settlements, among others. Perceived military performance (DV) was measured using a list of 14 items that measured self-reported performance . Military performance was measured as perceived competence used in practice. The self-reported military performance was measured after completing military training. Cronbach’s alpha for these 14 items was 0.944 in the current study see . The data were analyzed by SPSS 28v. The first G∗Power v3.1.9.4 test was conducted for the sample size evaluation of collected data. The statistical hypothesis testing was based on the 9 predictors that also accounted for the moderator, and with a significance level of 0.05, power of 0.95, and effect size of 0.1, it was indicated that a minimum sample size of 245 is required to reach statistical power see . Then, dachieved . Pearsonachieved . The proposed theoretical models  were tesBefore the causal relations assessment procedure, we first examined the relationship between our study constructs. Thus, the correlational analysis of perceived military performance (DV), hardiness (IV), conscientiousness (ME1), emotional stability (ME2), extraversion (ME3), agreeableness (ME4), openness to experiences (ME5), team cohesion (ME6), stress (MO1), and resilience (MO2) was conducted. p < 0.01) and psychological resilience , while negatively correlated with perceived stress . Hardiness was negatively correlated with perceived stress  and with agreeableness, one of the personality traits . On the other hand, hardiness was positively correlated with psychological resilience . Additionally, a few personality traits were positively correlated with perceived military performance: conscientiousness , emotional stability , and openness to experiences . The analysis results are presented in The correlation investigation revealed that perceived military performance was positively correlated with hardiness  is significantly different from an identity matrix. The explanatory power of the first factor was only 21.6% and was far from the recommended 50% threshold value [In addition, to prove that Common Methods Variance (CMV) cannot be a significant problem for this study, we used Harman’s one-factor test. The exploratory factor analysis conducted showed an appropriate value (0.867 > 0.8) for the Kaiser–Meyer–Olkin test. Furthermore, Bartlett’s sphericity test indicated with ld value .This study tested a moderating mediating effect of perceived stress (MO1) through personally based traits ) on the perceived military performance see . →ME1, β = 0.726, p < 0.001) and emotional stability , but negatively affected soldiers with agreeableness personality traits   see . →DV, β = −0.273, p < 0.001). Consciousness also positively influenced perceived military performance    see , Model 1001) see , Model 1p < 0.001), emotional stability (ME2p < 0.001), extraversion (ME3p < 0.001), and team cohesion (ME6p < 0.001). As a result, Hypotheses H2a, H2b, H2c, and H2f were confirmed. Conditional indirect analysis results for statistically significant causal relationships are presented in Thus, following Model 1, the hypothesis H2, if the perceived stress (MO1) will play a moderating role in the relationship between reserve soldiers’ personality traits and team cohesion, was examined. The significant conditional indirect effects were verified between hardiness and perceived military performance for reserve soldiers with personality traits such as conscientiousness  and openness to experiences (ME5). Hypotheses H2d and H2e were rejected. Additionally, the moderated mediating effect of perceived stress on reserve soldiers’ personality traits was confirmed by not including zero in the lower limit and the upper limit of the 95% confidence interval (CI) for extraversion , openness to experiences , and team cohesion . Accordingly, Hypotheses H3c, H3e, and H3f were confirmed see .p < 0.001), emotional stability , openness to experiences , and team cohesion   see , and posp < 0.001), emotional stability (ME2p < 0.001), openness to experiences (ME5p < 0.001), and team cohesion (ME6p < 0.001)—indicating that psychological resilience played a moderating role in the relationship between reserve soldiers’ personality traits, such as ME1, ME2, M5, and team cohesion (ME6). These results can confirm Hypotheses H4a, H4b, H4e, and H4f, that there is a moderating effect of resilience between mediated variables and perceived military performance .Furthermore, the results of the modeling allow us to confirm that the interaction of mediated variables and resilience significantly influenced perceived military performance—conscientiousness , emotional stability , openness to experiences , and team cohesion . Accordingly, Hypotheses H5a, H5b, H5e, and H5f were confirmed by not including zero in the lower limit and the upper limit of the 95% confidence interval. The statistically significant interaction effects of conscientiousness (ME1), emotional stability (ME2), openness to experiences (ME5), team cohesion (ME6), and resilience for perceived military performance are presented in In Model 2, reserve soldiers with less psychological resilience (M–1SD) were less likely to be confident in their perceived military performance when the levels of ME1, ME5, and ME6 were low rather than high see a,c,d. OnLastly, moderated mediating effects were also tested for whether study variables are moderated by marital status. For this modeling analysis, we used the PROCESS macro v3.5 Model 18, but the significance for marital status moderation was not confirmed.The significance area of the moderating variables  scores. The extraversion trait (ME3) was significant in areas where the MO1 scores were less than 0.07 or greater 1.28; the openness to experiences trait (ME5) was significant only above the value of MO1; team cohesion (ME6) showed significance when the perceived stress scores (MO1) were less than −1.128. In other words, ME3, ME5, and ME6 mediate the relationship between hardiness and perceived military performance in areas where the perceived stress (MO1 in Model 1) scores were less than average for extraversion (ME3) and openness to experiences (ME5), and for team cohesion (ME6), the area of MO1 was as significant for the low stress values area as it was for the high stress values area. Our findings suggest that reserve soldiers who reported high levels of perceived stress relied more heavily on team cohesion, which, in turn, contributed to improvements in their perceived military performance. Further, it can be pointed out that average and high stress affect the expression of the openness to experiences trait (ME5). In contrast, even lower-than-average levels of perceived stress can affect the expression of the extraversion trait (ME3) see , Model 1As for Model 2, where resilience (MO2) is the moderator see , Model 2Previous studies have shown that psychological hardiness affects the military performance of the tactical population in general  and miliThe first implication is related to hardiness and its effect on performance. As in previous studies ,26,67, op < 0.001). On the basis of the results of the mediated moderation, we can provide a more detailed explanation. A negative effect of perceived stress weakens the positive effect of hardiness on performance when the person’s consciousness, emotional stability, and openness to experiences are weakly expressed and team cohesion is low. These results are similar to a meta-analysis [The second implication is related to perceived stress and its negative impact on perceived military performance. Consistent with previous studies on perceived stress in the military environment , our resanalysis ,70, a laanalysis , and a manalysis , which fThe third implication is that high psychological resilience compensates for a lack of conscientiousness and emotional stability. Our result indicates that reservists with low psychological resilience were more at risk of showing lower performance due to their low levels of conscientiousness or openness to experiences. Conversely, if reservists have high resilience, then personality traits, whether expressed or not, will not diminish their perceived military performance. These results illustrate the classical definition of psychological resilience, which is described as a psychological ability or skill that could be applied in crises or stressful events ,73. ThesThe fourth implication is that very low levels of resilience could make soldiers act more within a team. This is especially true for team cohesion when hardiness is low. This finding is an extension of previous results on individual and team resilience, when these two variables were analyzed and developed separately . The fifth implication is that psychological resilience has a stronger effect than perceived stress on performance. These findings support an added value of a range of resilience training programs that teach positive coping skills ,29. MoreDespite these implications, there are some limitations to consider. First, data collection was carried out at a single military base (place) and for one period of the year (January) when reservist military training was carried out. Different locations and seasons could change the results to some extent, as location and senescence have been indicated in more recent studies to have some, albeit minor, effect on the results . This isThe study’s results revealed that psychological hardiness is a significant predictor of perceived military performance, and its impact is stronger under high perceived stress than that of personality traits and team cohesion. However, perceived stress has a direct negative effect on military performance, which weakens the positive effect of hardiness when personality traits and team cohesion are weakly expressed.In addition, high psychological resilience compensates for a lack of conscientious-ness and emotional stability, which are personality traits that are typically associated with high performance. As a result, improving the psychological resilience of reservists is crucial for enhancing their military performance.In contrast, very low levels of resilience could make soldiers act more within a team, particularly when hardiness is low. The findings of this study concluded that psychological resilience has a stronger effect on perceived military performance than perceived stress, suggesting the importance of promoting resilience training programs that can teach the soldiers positive coping skills.The study results are valuable for understanding the determinants of the perceived military performance of reservists, i.e., people who are fully employed in the civilian sector and perform military training and missions as part of their civil duty. In addition, the results are valuable for the further development of psychological resilience training pro-grams designed to achieve greater sustainability of military reserve forces, as well as de-signed to help reserve soldiers achieve better work–life–duty balance.


Autotetraploid leaves displayed lower Ψl and Gs in both treatments, but the lack of irrigation only affected Gs. Foliar cells of the adaxial epidermis and the spongy mesophyll contained linear pectin epitopes, whereas branched pectins were localized in the abaxial epidermis, the chloroplast membrane, and the sieve tube elements of the phloem. Cell and fruit organ size was larger in autotetraploid than in diploid mango trees, but the sugar content in the fruits was similar between both cytotypes. Specific cell wall hygroscopic pectins correlate with more stable Ψl of autotetraploid leaves under soil water shortage, keeping lower Gs compared with diploids. These preliminary results point to diploids as more susceptible to water deficits than tetraploids.The cultivation of mango in Mediterranean-type climates is challenged by the depletion of freshwater. Polyploids are alternative genotypes with potential greater water use efficiency, but field evaluations of the anatomy and physiology of conspecific adult polyploid trees under water stress remain poorly explored. We combined field anatomical evaluations with measurements of leaf water potential (Ψ Mangifera indica, Anacardiaceae) ranks fifth in terms of production among perennial fruit crops worldwide and is a staple crop for food security in many countries with tropical climates [Mango  as well [Malus, ,11; Ziziiziphus, ; Citrus,[Citrus, ,14), sugCapparis odoratissima [The stronger performance of polyploids under water deficit conditions has been correlated with differences in foliar elasticity and hygroscopicity between diploids and tetraploids, traits that correlate with cell size allometries, such as the escalation of stomatal guard cell size or the radius of vascular conduits . Differeatissima , and theIn this work, we compared irrigated and non-irrigated diploid and autotetraploid mango leaves belonging to one tree per treatment of the cultivar ‘Kensington Pride’, in order to have a better knowledge of their chemical differences and preliminarily test the physiological performance of conspecific trees with doubled chromosome numbers under drought.In the Mediterranean climate of the region in which the experiments were performed, precipitations in the winter season (November to February) of 2021 were above 120 mm, while average temperatures rarely dropped below 10 °C . Howeverp < 0.001), despite the fact that they were located in the same field. These differences became stronger at the superficial horizons (10–20 cm), with a volumetric water content of 30–40% during the summer season.Volumetric water content in the soil with supplemental irrigation ranged between 70% of the maximum value all year long in the most superficial horizons (10–20 cm deep) and 80% in the deepest horizon layers (130–140 cm) . In contp < 0.05), wider , and longer  than fruits from the irrigated diploid (p < 0.05).Two years after the suppression of irrigation, the morphological differences between trees with and without irrigation were clear to the naked eye A–D. Irri diploid E, brix dp < 0.05 indicates that water potential variation was more attributed to ploidy than to irrigation.The midday leaf water potential of diploid leaves with irrigation on demand was maintained around −0.2 MPa or higher all year round. Irrigated tetraploid leaves showed similar values compared with diploids during the months with milder temperatures , but during the hottest months, when most of the fruit development process takes place, their leaf water potential at midday dropped slightly to −0.3 MPa A. Striki2O m2 s−1, whereas leaves from tetraploids maintained twice lower values  (s), but leaves of diploids maintained higher values (below 500 mmol H2O m2 s−1), compared with those of tetraploids (below 350 mmol H2O m2 s−1) , irrigation , and their interaction . Comparing Gs by date of measurement, significant differences were attributed to ploidy in most months, but irrigation had a significant effect in August and September, when evapotranspiration demands were at their highest.Leaves from the diploid tree with supplemental irrigation reached the highest stomatal conductance measurements from June to September (that represents most of the fruit growing season) with values ranging between 500 and 700 mmol H m2 s−1) C. Leaves m2 s−1) D. AggregThe mango leaves accumulated high amounts of insoluble polysaccharides in the cell walls of the adaxial and abaxial epidermis and on the external side of vascular bundles A. The sqTo obtain a deeper understanding of the nature of the saccharide compounds, the immunolocalization of two pectin epitopes in the cell walls revealed a clear topological pattern within leaves of both ploidies  in autoAnnona . HoweverAnnona . The sizAnnona  and pereAnnona ,34 and hAnnona ,36,37, aAnnona ,38,39. Dotstocks ,41. Someotstocks . The posotstocks , measureotstocks .At the whole-plant level, soil water shortage impaired new biomass production in both diploid and tetraploid genotypes, pointing to irrigation as crucial for good productivity of this crop under our climatic conditions. Indeed, rainfall dropped sharply from 60.5 mm on average in May to 5 mm in June, being almost 0 in July and August, when maximum temperatures reached around 38 °C. This lower biomass production is associated with the suppression of reproductive development in the following spring, which was more dramatic in the diploid than in the tetraploid tree. Although we are aware of the limitations of our study in terms of number of trees analyzed, the preliminary results obtained show that the processes of flower induction and flower development are less affected by soil water deficit in tetraploids, while supplemental irrigation is required for appropriate fruit set and development. These preliminary results open the way for further studies in the following years when additional trees are available and a study at a larger scale can be designed.Autotetraploid mango genotypes are rare, but among the four trees of mango cv ‘Kensington Pride’ maintained in our mango germplasm collection at IHSM La Mayora , through a combination of molecular markers and flow cytometry (the combination of both methods avoids confusion with possible aneuploids or mixoploids), two of them were characterized as diploids and the other two as autotetraploids  that track the humidity of the soil for each irrigation treatment at different horizons belowground each separated by 10 cm, from the surface to a 140 cm depth. The sensors were calibrated at installation by saturating the contacting soil area with water, according to the manufacturer’s instructions. Measures were taken every 15 min, sent through a wireless system to a server, and recorded. Rainfall, relative humidity, and minimum and maximum temperatures were also tracked and recorded with environmental sensors.https://www.pmsinstrument.com, accessed on 1 September 2019) in 3 fully developed mature leaves per tree , avoiding leaves from new growth flushes, which typically display water potentials close to 0 . Concomitantly, stomatal conductance  was estimated with a steady-state leaf porometer  on four fully developed leaves per tree under the two treatments  oriented to the four cardinal points. The sensor head was calibrated daily before performing Gs measurements in the field according to the manufacturer’s protocol.Midday leaf water potential was evaluated bi-weekly from April to September using a Scholander pressure chamber , n = 3) were fixed in 100% dry methanol, then washed in 100% ethanol three times for 1 h each [http://www.plantprobes.net, accessed on 20 October 2019), which recognizes a linear pectic 1,4-galactan epitope in the cell walls, and LM26 , which detects a branched β-1,6-galactosyl substitution of pectic β-1,4-galactan, a pectic rhamnogalacturonan-I [In order to study the polysaccharides present in the leaf tissues, the tertiary veins and the aerials of three leaves per ploidy (1 h each  prior touronan-I . Negativp < 0.05. Fruit weight, length, width, and degrees Brix were compared between ploidies using a one-way ANOVA at a p < 0.05. Aggregated data of Gs and Ψ were compared with a two-way ANOVA using ploidy and irrigation as independent variables. The same test was used to evaluate each day of measurement individually.Soil water content was averaged per month and compared across similar horizons between both irrigation treatments using a one-way ANOVA at a Our work is based on preliminary data obtained from few samples, but suggests a better performance of autotetraploid mango trees under soil water deficit scenarios, supporting the long-held hypothesis that polyploids have more robust performance under water stress than diploids ,46. Work


Chambardia rubens. Mussels were treated with 100 and 1000 µg Cu L−1 of copper oxide nanoparticles (CuONPs) or ionic copper (Cu2+) for 3, 7, and 14 days. The Cu accumulation and markers of oxidative stress in the digestive glands and gills were evaluated. The results show that the digestive gland collected higher levels of the two forms of copper than the gills. Exposure to CuONPs or Cu2+ induced significant elevations in superoxide dismutase, glutathione peroxidase and lipid peroxidation. Notably, a significant decrease was observed in the glutathione levels after exposure to both copper forms. CuONPs only induced a significant increase in glutathione reductase and glutathione S-transferase. The ionic copper only induced a significant decrease in catalase activities in the gill tissues. Overall, CuONPs and Cu2+ provoked oxidative stress, and further research is needed to clarify their genotoxic and neurotoxic effects on freshwater mussels and other biota.Copper nanoparticles are widely incorporated into many applications, including air and liquid filters, wood preservatives, batteries, thermal and electrical conductivity, inks and skin products. Their potential toxicity and environmental fate, however, are poorly studied in the freshwater bivalves. The aim of the present study was to evaluate the different effects of copper oxide nanoparticles and ionic copper on the digestive glands and gills of the mussel  Nanotechnology is an evolving field focused on the research and development of nanoparticles with sizes less than 100 nm (NPs). Currently, engineered NPs are considered environmental pollutants because of the development of their applications in many research and industrial fields, such as food and food packaging, medicine, electronics, bioremediation, fuel catalysts, cosmetics, paints, coatings, and water treatment .NPs have unique characteristics that might increase chemical reactivity and biological activity due to their size. NPs can induce free radicals, resulting in severe toxicity in living organisms . MoreoveEscherichia coli, Bacillus subtilis, and Staphylococcus aureus); protozoa (Tetrahymena thermophila); algae (Pseudokirchneriella subcapitata) and crustaceans  in addition to zebrafish (Danio rerio)  in addition to lipid peroxidase (LPO). Furthermore, histological changes in the digestive gland and gills of this bivalve can be used successfully to monitor the effects of exposure to both copper forms.CuONPs showed toxicity to both vertebrates and invertebrates via free radical (ROS) release, which might result in the alteration of the antioxidant capacity by disturbing the activities of antioxidant enzymes ,30. Althg for 15 min and properly washed three times with deionized water using sonication and centrifugation to remove the excess unreacted nitrate and urea. Then, the CuONP precipitate was left to dry in an oven at 100°C for 24 h and then annealed at 300°C for 4 h. The CuONPs were stored in closed bottles at room temperature for further experiments.Copper nitrate and urea were used as the starting precursors in the preparation of CuONPs. Separate homogeneous solutions of copper nitrate (0.1 M) and urea (0.1 M) were prepared first using deionized water. A 50 ml aliquot of urea was added dropwise with a burette to 50 ml of copper nitrate solution using constant stirring at 80°C for 3 h. The precipitate was then separated via centrifugation at 10,000 × The average size and zeta potential for CuONPs dispersed in deionized water were analyzed at 25°C by dynamic light scattering (DLS) using a Malvern Zetasizer 2000 . Nanoparticles were suspended in deionized water by applying sonication before each measurement. Additionally, the shape and particle size of the CuONPs were examined by TEM analysis using a JEOL JEM-2100 electronic microscope . The specimens for TEM measurements were prepared by depositing a droplet of CuONP suspension on a carbon-coated film (400 mesh) copper grid, after which the solvent was evaporated in the air at 25°C.Chambardia rubens mussels (75 ± 5.8 mm) were collected from the Banha region  of Egypt. Then, they were exposed to steady temperature and aeration for one week for the acclimation process. The mussels were divided (approximately 2.5 mussels/L) into 20 L tanks filled with 15 L of fresh water in triplicate. The first three mussel tanks were exposed to 100 and 1000 µg Cu L−1 by adding CuONPs. The second three tanks were exposed to 100 and 1000 µg Cu L−1 by using CuSO4. The last three tanks served as controls. The copper exposure (CuONPs and Cu2+) was continued for 14 days, and the water was renewed every 12 h with fresh water that had been re-dosed with CuONPs and Cu stock solutions. CuONP solutions were sonicated for 30 min (45 kHz frequency) before each renewal to prevent aggregation. The control tank water was also renewed every 12 h. The mussels were not fed during the exposure, and no mortalities were observed. Cu-treat (CuONPs or Cu2+) and control mussels were collected after 3, 7, and 14 days, and then their biotic parameters were measured. The collected specimens were dissected; their digestive glands and gills were separated, immediately frozen and stored at −80°C until further analysis.3. The digested samples were adjusted to 50 ml using deionized water in 50 ml volumetric flasks and then analyzed at 324.8 nm using a flame atomic absorption spectrophotometer . The absorbance of the sample solution was measured against the blank solution. The difference between the absorbance of the sample and blank solutions at 324.8 nm was used as an analytical signal. A calibration curve was constructed by plotting the analytical signal versus the Cu(II) concentration in a series of working standard solutions. The amounts of copper in the digestive glands and gills are presented as µg/g wet tissue weight.A stock standard solution of Cu(II) ions at a concentration of 1000 μg/ml was prepared from copper(II) sulfate anhydrous (≥ 99.0) (Merck), and the working standard solutions were obtained daily by stepwise dilutions of the stock solution with doubly distilled water. The copper concentrations in the digestive gland and gill tissues were estimated using the method by Bagherian et al. . Digestig for 10 min at 4°C. The supernatants were collected and stored at −80°C for analysis. The homogenized digestive gland and gill total protein content was estimated according to Lowry et al. [The activities of antioxidant enzymes were determined in the digestive glands and gill cytosolic fraction of five mussels from the control and treated groups. The digestive glands and gills were immediately dissected and weighed. Ice-cold 50 mM Tris-HCl buffer (pH 7.4) homogenates (10% w/v) were prepared by mixing a part of the gills or digestive glands in ice-cold buffer using a tissue homogenizer and centrifuged at 3000 × y et al.  using boy et al. , Aebi [3y et al. , Paglia y et al. , and Facy et al. , respecty et al. . Furthery et al. , the lipBased on Carleton et al., the mussel digestive glands and gills were removed and processed  and thenP values < 0.05 were considered statistically significant.The values are expressed as the means ± standard deviation (SD) of five mussels. The data were analysed using a one-way analysis of variance (ANOVA), and then, post-hoc Duncan multiple tests were performed. DLS is an important and emerging technique for determining the particle sizes in a colloidal solution based on Brownian movement . The sizThe zeta potential is a significant measurement for estimating the surface charge of nanoparticles, which is useful for determining their colloidal stability . Hence, The morphology of the prepared CuONPs was examined using TEM, and a typical image is depicted in Cu accumulation in different mussel tissues depends on the metal form and the period of exposure. After 3, 7, and 14 days of exposure, mussels treated with ionic copper displayed a significant increase in Cu content compared with NP-exposed and control mussels. The digestive gland accumulated higher levels of copper than the gills. Different antioxidant enzymatic activities were found in the mussel digestive glands and gills after exposure to nanoparticles and ionic forms of copper. In the digestive glands, the LPO level in mussels exposed to CuONPs and ionic copper for 3, 7, and 14 days increased significantly in comparison with the control animals. The LPO levels were elevated over time in mussels treated with both forms of copper, as shown in In the gills, the LPO level in mussels exposed to CuONPs and ionic copper for 7 and 14 days increased significantly in comparison with the control animals. The LPO level increased over time in mussels treated with both forms of copper A. The SOC. rubens mussels showed normal architecture, comprising a large number of digestive tubules. The tubules were isolated from each other by connective tissue. Columnar epithelial cells and secretory cells line each digestive tubule, which are supported by a basement membrane  and lead to oxidative stress  that cauCoelatura aegyptiaca and demonstrated that mollusc GSH concentrations drop as a result of metal exposure and that the metal has a strong affinity for the GSH molecule. The exposed sulfhydryl groups of GSH can bind to a number of electrophilic radicals and metabolites, potentially increasing cell sensitivity to a variety of toxic substances [GSH is the most prevalent nonprotein thiol molecule in the body and plays a variety of critical physiological roles, including catalysis, metabolism, and transport . Moreovebstances . TherefoC. rubens compared with the control group. Our findings are similar to those of Buffet et al. [Scrobicularia plana exposed to nanoparticles of copper oxide (CuONP) during 16 days of the experiment. Unlike the present study, Fahmy et al. [Coelatura aegyptiaca was exposed to ZnNPs.The GST enzyme participates in the detoxification process by facilitating glutathione conjugation with a variety of endogenous and xenobiotic compounds to form less toxic and more hydrophilic molecules . This stt et al. , who fouy et al.  found a CAT and SOD are categorized as indispensable first-line defence antioxidants based upon their response to free radical invasion. In particular, superoxide anion radicals are generated in normal metabolism, primarily through the mitochondrial energy production pathway . This st2O2 from the SOD activity increase are not detoxified because of a decrease in CAT activity. The inhibition of CAT may occur either in response to an increase in the inhibitor superoxide anion or to a decrease in NADPH, since this coenzyme is required for full CAT activity [C. aegyptiaca mussels to a decreased ability to neutralize the ROS and a higher sensitivity to oxidative stress.Notably, the subsequent higher levels in Hactivity . Moreoveactivity  linked aS. plana mussels, the SOD activity  was higher than that after ionic copper exposure. Similarly, Gomes et al. [M. galloprovincialis and found that CuONPs caused oxidative damage by exceeding the gill antioxidant defence system, but the enzymatic activity remained constant or increased following ionic copper exposure.Gomes et al.  and Ruizs et al.  studied +/K+, high Ca ion flow and activation of catabolic enzymes such as proteases, phospholipases and nucleases [Corbicula fluminea induced slightly elevated levels of LPO in the presence of Cu >1 mg L−1 in water. Moreover, in Gomes et al. [Mytilus galloprovincialis mussels exposed to CuONPs and Cu2+ despite the efficiency of different antioxidants. In addition, exposure to CuONPs in human cells and E. coli led to lipid peroxidation, oxidative damage, and an increase in ROS, all contributing to oxidative stress [Perna viridis.LPO is produced as a response to peroxidative damage by polyunsaturated fatty acids . Increasucleases . In the ucleases  found ths et al. , the LPOe stress . In conte stress  reportedC. rubens are similar to many reports on different bivalve species [C. rubens to CuONPs and Cu2+.The histological studies on the digestive glands and gills of  species ,65,66. M species  reported species . TherefoMytillus galloprovincialis mussel following exposure to CuONPs. Hemocytic infiltration may represent a repair process following tissue damage [In the present study, the atrophy of the digestive tubules and the changes in the morphology of the digestive tubules were observed histopathologically and are considered nonadaptive responses to pollution exposure . Furthere damage . Unlike e damage  discoverChambardia rubens. Both forms of copper were able to induce oxidative stress in the mussel digestive glands and gills. The distinct efficiency of enzymatic and nonenzymatic antioxidants and LPO in mussel tissues is dependent on the used Cu form and the exposure time. Digestive gland of the bivalve C. rubens showed more sensitivity to the oxidative stress than gills tissues for both copper forms and it was the main target tissue for Cu accumulation and pronounced histopathological alterations. In the future studies, CuONPs toxicity requires more investigation to determine if the observed toxic effects are primarily due to free Cu ions dissociated from the NPs or to the mixture of the NPs’ effects.Up to our knowledge, this is the first study to elucidate the toxic effects of copper along with its nanoform (Cu ions and CuONPs) on the bivalve


Background. Triggering final oocyte maturation is a key step of ovarian stimulation. Although previous studies demonstrated a negative association between female BMI and serum hCG levels, little evidence is available regarding the association between oocyte yield and patients’ BMI. The scope of the current study was to examine whether the efficiency of the r-hCG and triptorelin to trigger final oocyte maturation may be associated with patients’ BMI or weight. Methods. This is a retrospective observational study including 5190 ovarian stimulation cycles performed between January 2019 and September 2022 in the Reproductive Medicine Department of Dexeus University Hospital. Cycles were analyzed according to the type of trigger . The primary outcome measures were oocyte maturation rate (MII/oocytes) and FOI (oocytes/AFC); secondary outcomes were oocyte and MII yield. Results. Multivariable regression analysis, adjusting for confounding factors, demonstrated that BMI was not associated with oocyte maturation rate , FOI , number of oocytes  or MIIs  retrieved. Similarly, all analyses conducted considering patients’ weight failed to reveal any association. Conclusion. Our study demonstrates that, independent of the type of trigger, patients’ BMI and weight are not associated with oocyte yield, maturation, or FOI. Triggering final oocyte maturation is a key step of ovarian stimulation for IVF/ICSI treatment since it represents the process by which the oocyte resumes meiosis to transition from the metaphase I to the metaphase II stage of development and attains competence for fertilization by a spermatozoon .Under physiological conditions, oocyte maturation is caused by the spontaneous mid-cycle surge of luteinizing hormone (LH), but in assisted human reproduction protocols it has been replaced for decades by the administration of human chorionic gonadotropin (hCG). hCG has sufficient homology to LH and is able to activate the LH receptor , sharingThe first hCG preparations have been developed in the late 1930s . For almMore recently, two different types of triggering have been adopted in everyday clinical practice. First of all, the introduction of the GnRH agonist (GnRHa) trigger, which has been widely adopted in freeze-all protocols, since it is considered a breakthrough towards a safer OHSS-free clinic . The secNevertheless, despite the different options that have been developed over the years in order to optimize the triggering of final oocyte maturation, little evidence is available regarding the actual association between the trigger’s efficacy and patients’ BMI. Previous studies evaluated the association between BMI and ART outcomes, demonstrating the need for higher doses of drugs to stimulate ovulation , changesTaking into account the accumulating evidence on the novel methods of triggering final oocyte maturation and the unclear evidence on whether patients’ body weight and BMI may be associated with oocyte yield, we set out to perform a large retrospective study in order to examine whether the efficacy of the r-hCG, triptorelin (GnRH agonist) or dual trigger (combination of rhCG and GnRH agonist) to trigger final oocyte maturation is associated with female BMI or body weight. Study design. This is a retrospective observational study including 5190 consecutive cycles of ovarian stimulation cycles (OS) performed between January 2019–September 2022 in the Reproductive Medicine Department of Dexeus University Hospital. We included only cycles from patients aged 18 and 40 years, who planned to undergo ovarian stimulation for IVF/ICSI using their own gamete, for oocyte donation, or medical and elective fertility preservation in a GnRH antagonist or a progestin-primed ovarian stimulation (PPOS) protocol. Patients who did not meet these criteria were excluded.Procedures. Controlled ovarian stimulation was performed with recombinant follicle-stimulating hormone (FSH) and/or human menopausal gonadotropin (HMG) at a starting dose of 150–300 IU depending on patients’ ovarian reserve and body mass index (BMI). Control of LH surge was accomplished by a flexible GnRH antagonist or PPOS protocol. Patients’ responses to stimulation were monitored using transvaginal ultrasound starting from day 6 of ovarian stimulation, the frequency of which was determined by the clinician according to the number and diameter of growing follicles. Daily administration of a GnRH antagonist (Ganirelix 0.25 mg) was started when the leading follicle was 13–14 mm in diameter and continued until the day of the trigger of the ovulation, while in PPOS protocol Desogestrel 75 mg or micronized progesterone 200 mg was administrated orally from the beginning of ovarian stimulation until trigger day. As soon as at least two-three follicles had reached 18 mm in diameter, ovulation was triggered with subcutaneous administration of triptorelin at the dose of 0.2 mg or 250 mcg of r-hCG, or a combination of both in a dual trigger. Oocyte retrieval was performed 36 h after trigger injection under sedation; during the procedure, all the follicles observed were aspirated.oocyte maturation rate, defined as the number of MII oocytes divided by the number of oocytes retrieved per patient; andFOI (Follicle to Oocyte Index) defined as the ratio between the number of oocytes collected at the ovum pick-up and the number of antral follicles at the beginning of OS .Outcomes. Given the retrospective nature of the study and the no-uniform baseline characteristics of the cycles, we elected primary outcomes indexes taking into account the variability of ovarian reserve. Primary outcomes measures are as follows:Secondary outcomes include the number of oocytes retrieved and the number of MII.Ethics approval. The study has been approved by the local ethical committee. All women were treated at the Reproductive Unite in Dexeus University Hospital, Barcelona (Spain).p-value of <0.05 was considered statistically significant. R software  and IBM© SPSS© Statistics v22  were used to perform all the analyses.Statistical analysis. Continuous variables were expressed as mean and standard deviation, whereas categorical variables were expressed as frequencies and percentages. Primary outcomes of the study were rates. Oocyte maturation rate and FOI were expressed as % [95% CI]. For bivariate analysis, the ANOVA test was used to compare patient baseline characteristics and reproductive outcomes among the three groups based on trigger dose. For the primary outcome, a generalized mixed model was used, and results were expressed as odds ratios (OR) with 95% confidence interval. The cycle was added as a random effect since each cycle has more than one oocyte. Linear regression models were used for FOI, number of oocytes retrieved, and number of MII. In this model, results were expressed as a coefficient (beta) with a 95% confidence interval. All models were adjusted by BMI, type of trigger, type of treatment, and interactions between BMI and type of trigger, and age with type of treatment. Dual trigger and oocyte donation were taken as reference groups. All tests were 2-tailed; a Patients’ baseline characteristics: Overall, 5190 ovarian stimulation cycles (3852 patients) were analyzed: 2691 (51.8%) cycles triggered with subcutaneous administration of 0.2 mg of GnRHa (triptorelin), 1110 (21.4%) with 250 mcg of r-hCG, and 1389 (26.8%) with a dual trigger (combination of both 0.2 mg triptorelin + 250 mcg of r-hCG) . Among tStimulation outcomes. Oocyte yield and MII oocyte yield were different among groups, with a higher number of oocytes (15.95 ± 8.88) and MIIs (12.31 ± 7.27) in the triptorelin group as compared with cycles triggered with rhCG (7.83 ± 5.42 and 5.86 ± 4.22 respectively) or dual trigger (8.51 ± 5.70 and 6.44 ± 4.54 respectively) . BMI and oocyte yield and maturation. A generalized mixed model, adjusting for confounding factors  and adjusting for the cycle as a random effect, demonstrated that BMI was not associated with oocyte maturation rate . Linear regression models adjusting for the same confounding factors, showed that BMI was not associated with FOI   and numbBody weight and oocyte yield and maturation. Similarly, the same models were applied for body weight. These models failed to demonstrate any association between body weight with either oocyte maturation rate , FOI  , number To our knowledge, this is the first and the largest study evaluating the association between patients’ BMI and body weight in the efficiency of different final oocyte maturation triggering protocols. Although we see differences in oocytes and MIIs in the three groups , these dOur large observational study confirms that trigger dose is not related to patients’ BMI and weight, as no significant differences have been found in maturation rate and FOI.2.Over the years, the correlation between patients’ BMI or weight and trigger efficiency has been investigated focusing on hCG serum concentration after the rhCG trigger. Although a negative correlation was identified between hCG serum level and BMI after administration of 250 mcg of rhCG on trigger day, no correlation was found with reproductive outcome variables studied  ,21. Thes2 [A RCT published in 2010 comparing two doses of rhCG for final oocyte maturation (250 vs. 500 μg) in 105 overweight and obese women, failed to demonstrate any difference in terms of obtained total or MII oocytes and cycle parameters in patients with BMI > 26 kg/m2 . Our stu2 had a significantly higher number of MII oocytes as compared with women with BMI ≥ 25 Kg/m2. A potential explanation for the different results could be the small sample size in Lainas’ study, as well as the lack of multivariate analysis and the use of variables such as the number of oocytes and MII rather than maturation rate and FOI. On the contrary, our results are in agreement with a RCT conducted in women with low BMI in which no significant differences in the number of oocytes retrieved (18.4 ± 8.8 vs. 18.7 ± 8.9 vs. 17.8 ± 10.7) or mature oocytes (16.0 ± 8.5 vs. 15.9 ± 7.8 vs. 14.7 ± 8.4) when comparing doses ranging from 0.2 mg to 0.4 mg [As far as the GnRHa trigger dose is concerned, our study is in contrast with a small retrospective study, claiming a negative association between BMI and oocyte maturity following the GnRH agonist (Triptorelin 0.2 mg) trigger . In thiso 0.4 mg .Finally, our study failed to find any association between BMI and maturation rate, FOI, oocyte, and MII yield following dual trigger. Although no previous study has examined the association between BMI and response in dual trigger cycles, we believe that our sample size is robust enough to exclude such an association.In terms of clinical practice recommendation, the current large retrospective study provides robust evidence to exclude a potential association between patients’ BMI or weight and the efficiency of the rhCG and triptorelin to trigger final oocyte maturation. This suggests that clinicians should not be concerned about the triggered dose in overweight and obese women, given that even in such cases the recommended doses of 250 mcg in rhCG, of 0.2–0.4 mg in triptorelin or the combination of both in the dual trigger are sufficient to successfully induce final oocyte maturation.The major strengths of the study are the sample size and the robust analysis performed. Although we cannot exclude the presence of residual bias despite the large series, we do believe that such a sort of bias is indeed limited owing to the adoption of multiple regression models and the indexes like maturation rate and FOI we adopted to account for confounding factors.In conclusion, although previous small observational studies supported an association between BMI and hCG levels, our large analysis of > 5000 cycles clearly shows that the efficiency of rhCG, triptorelin, or dual trigger is not associated with the patient’s BMI and weight, as no significant differences were found in maturation rate and FOI. In this context, clinicians should not be concerned about a suboptimal response following triggering final oocyte maturation with 250 mcg of rhCG, 0.2–0.4 mg of triptorelin, or dual in overweight or obese patients.