Pairwise Tests Research Articles

Ibrutinib combined with immunochemotherapy with or without autologous stem-cell transplantation versus immunochemotherapy and autologous stem-cell transplantation in previously untreated patients with mantle cell lymphoma (TRIANGLE): a three-arm, randomised, open-label, phase 3 superiority trial of the European Mantle Cell Lymphoma Network

Adding ibrutinib to standard immunochemotherapy might improve outcomes and challenge autologous stem-cell transplantation (ASCT) in younger (aged 65 years or younger) mantle cell lymphoma patients. This trial aimed to investigate whether the addition of ibrutinib results in a superior clinical outcome compared with the pre-trial immunochemotherapy standard with ASCT or an ibrutinib-containing treatment without ASCT. We also investigated whether standard treatment with ASCT is superior to a treatment adding ibrutinib but without ASCT. The open-label, randomised, three-arm, parallel-group, superiority TRIANGLE trial was performed in 165 secondary or tertiary clinical centres in 13 European countries and Israel. Patients with previously untreated, stage II-IV mantle cell lymphoma, aged 18-65 years and suitable for ASCT were randomly assigned 1:1:1 to control group A or experimental groups A+I or I, stratified by study group and mantle cell lymphoma international prognostic index risk groups. Treatment in group A consisted of six alternating cycles of R-CHOP (intravenous rituximab 375 mg/m2 on day 0 or 1, intravenous cyclophosphamide 750 mg/m2 on day 1, intravenous doxorubicin 50 mg/m2 on day 1, intravenous vincristine 1·4 mg/m2 on day 1, and oral prednisone 100 mg on days 1-5) and R-DHAP (or R-DHAOx, intravenous rituximab 375 mg/m2 on day 0 or 1, intravenous or oral dexamethasone 40 mg on days 1-4, intravenous cytarabine 2 × 2 g/m2 for 3 h every 12 h on day 2, and intravenous cisplatin 100 mg/m2 over 24 h on day 1 or alternatively intravenous oxaliplatin 130 mg/m2 on day 1) followed by ASCT. In group A+I, ibrutinib (560 mg orally each day) was added on days 1-19 of R-CHOP cycles and as fixed-duration maintenance (560 mg orally each day for 2 years) after ASCT. In group I, ibrutinib was given the same way as in group A+I, but ASCT was omitted. Three pairwise one-sided log-rank tests for the primary outcome of failure-free survival were statistically monitored. The primary analysis was done by intention-to-treat. Adverse events were evaluated by treatment period among patients who started the respective treatment. This ongoing trial is registered with ClinicalTrials.gov, NCT02858258. Between July 29, 2016 and Dec 28, 2020, 870 patients (662 men, 208 women) were randomly assigned to group A (n=288), group A+I (n=292), and group I (n=290). After 31 months median follow-up, group A+I was superior to group A with 3-year failure-free survival of 88% (95% CI 84-92) versus 72% (67-79; hazard ratio 0·52 [one-sided 98·3% CI 0-0·86]; one-sided p=0·0008). Superiority of group A over group I was not shown with 3-year failure-free survival 72% (67-79) versus 86% (82-91; hazard ratio 1·77 [one-sided 98·3% CI 0-3·76]; one-sided p=0·9979). The comparison of group A+I versus group I is ongoing. There were no relevant differences in grade 3-5 adverse events during induction or ASCT between patients treated with R-CHOP/R-DHAP or ibrutinib combined with R-CHOP/R-DHAP. During maintenance or follow-up, substantially more grade 3-5 haematological adverse events and infections were reported after ASCT plus ibrutinib (group A+I; haematological: 114 [50%] of 231 patients; infections: 58 [25%] of 231; fatal infections: two [1%] of 231) compared with ibrutinib only (group I; haematological: 74 [28%] of 269; infections: 52 [19%] of 269; fatal infections: two [1%] of 269) or after ASCT (group A; haematological: 51 [21%] of 238; infections: 32 [13%] of 238; fatal infections: three [1%] of 238). Adding ibrutinib to first-line treatment resulted in superior efficacy in younger mantle cell lymphoma patients with increased toxicity when given after ASCT. Adding ibrutinib during induction and as maintenance should be part of first-line treatment of younger mantle cell lymphoma patients. Whether ASCT adds to an ibrutinib-containing regimen is not yet determined. Janssen and Leukemia & Lymphoma Society.

Spiral time-of-flight magnetic resonance angiography for intracranial vascular imaging: performance compared to conventional Cartesian angiogram.

Computed tomography angiography (CTA) and digital subtraction angiography (DSA) usually raise the risk of potential malignancies with cumulative radiation doses. Current time-of-flight magnetic resonance angiography (TOF-MRA) (dubbed as cTOF), which is based on Cartesian sampling mode, may show limited diagnostic conspicuity at sinuous or branching regions. It is also prone to relatively high false positive diagnoses and undesirable display of distal intracranial vessels. This study aimed to use spiral TOF-MRA (sTOF) as a noninvasive alternative to explore possible improvement, such that the application of magnetic resonance angiography (MRA) can be extended to facilitate clinical examination or cerebrovascular disease diagnosis and follow-up studies. Initially, 37 patients with symptoms of dizziness or transient ischemic attack were consecutively recruited for suspected intracranial vascular disease examination from Zhongshan Hospital of Xiamen University between July 2020 and April 2021 in this cross-sectional prospective study. After excluding 1 patient with severe scanning artifacts, 1 patient whose scanning scope did not meet the requirement, and 1 patient with confounding tumor lesions, a total of 34 participants were included according to the inclusion and exclusion criteria. Each participant underwent intracranial vascular imaging with both sTOF and cTOF sequences on a 3.0 T MR scanner with a conventional head-neck coil of 16 channels. Contrast CTA or DSA was also performed for 15 patients showing pathology. Qualitative comparisons in terms of image quality and diagnostic efficacy ratings, quantitative comparisons in terms of signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), vessel length, and sharpness were evaluated. Pair-wise Wilcoxon test was performed to evaluate the imaging quality derived from cTOF and sTOF acquisitions and weighted Cohen's Kappa was conducted to assess the rating consistency between different physicians. Compared to cTOF, sTOF showed better performance with fewer artifacts. It can effectively alleviate false positives of normal vessels being misdiagnosed as aneurysm or stenosis. Improved conspicuity was observed in cerebral distal regions with more clearly identifiable vasculature at finer scales. Quantitative comparisons in selected regions revealed significant improvement of sTOF in SNR (P<0.01 or P<0.001), CNR (P<0.001), vessel length (P<0.001), and sharpness (P<0.001) as compared to cTOF. Besides, sTOF can depict details of M1 and M2 segments of middle cerebral artery (MCA) at metallic implant region, showing its resistance to magnetic susceptibility. The sTOF shows higher imaging quality and lesion detectability with reduced artifacts and false positives, representing a potentially feasible surrogate in intracranial vascular imaging for future clinic routines.

Influence of base designs on the manufacturing accuracy of vat-polymerized diagnostic casts using two different technologies

Statement of problemDiagnostic casts can incorporate different base designs and be manufactured using different vat-polymerization technologies. However, the influence of the interrelation between the base design and the 3D printing technology on the casts' final accuracy remains unclear. PurposeThe purpose of this in vitro study was to assess the influence of different base designs of 3D printed casts on the accuracy of 2 vat-polymerization technologies. Material and methodsA digital maxillary cast was obtained and used to generate 3 different base designs: solid (S group), honeycombed (HC group), and hollow (H group). The HC and H groups were subdivided based on the wall thickness of the cast design, resulting in 2 subgroups with thicknesses of 1 mm (HC1 and H1) and 2 mm (HC2 and H2) (N=100, n=10). Eleven reference cubes were added to each specimen for subsequent measurements. Specimens were manufactured by using 2 vat-polymerization 3D printers: Nextdent 5100 (ND group) and Sonic Mini 4K (SM4K group) and a resin material suitable for both 3D printers (Nextdent Model 2.0). A coordinate measuring machine quantified the linear and 3-dimensional discrepancies between the digital cast and each reference specimen. Trueness was defined as the average absolute dimensional discrepancy between the virtual cast and the specimens produced through additive manufacturing (AM), while precision was delineated as the standard deviation in dimensional discrepancies between the digital cast and the AM specimens. The data were analyzed using the Kruskal-Wallis and Mann-Whitney U pairwise comparison tests (α=.05). ResultsFor the NextDent group the trueness ranged from 21.83 µm to 28.35 µm, and the precision ranged from 17.82 µm to 37.70 µm. For the Phrozen group, the trueness ranged from 45.15 µm to 64.51 µm, and the precision ranged from 33.51 µm to 48.92 µm. The Kruskal-Wallis test showed significant differences on the x-, y-, and z-axes and in the 3D discrepancy (all P<.001). On the x-axis, the Mann-Whitney U test showed significant differences for the Phrozen group between the H-2 and H-1 groups (P=.001), H-2 and S groups (P<.001), and HC-2 and S groups (P=.012). On the y-axis, significant differences were found in the Phrozen group between the H-2 and H-1 groups (P=.001), the H-2 and S, H-1 and HC-1, and HC-1 and S groups (P<.001), the H-1 and HC-2 groups (P=.007), and the HC-2 and S groups (P=.009). The NextDent group exhibited significant differences, particularly among the HC-1 and H-2 groups (P=.004), H-1 (P=.020), and HC-2 (P=.001) groups; and on the z-axis significant differences were found in the Phrozen group between the H-2 and H-1 and S groups and the HC-2 group and H-1 and S groups (both P<.001). In the NextDent group, significant differences were found between the H-2 and HC-2 (P=.047) and HC-1 (P=.028) groups. For the 3D discrepancy analysis, significant differences were found in the Phrozen group between the H-2 and H-1 and S groups (P<.001), the H-1 and HC-2 groups (P=.001), the S and HC-1 and HC-2 groups (P<.001), and the H-1 and HC-1 groups (P=.002). In the NextDent group, significant differences were observed between the H-2 and HC-1 groups (P=.012). ConclusionsThe accuracy of digital casts depends on the manufacturing trinomial and base design of the casts. The honeycomb and hollow based designs provided the highest accuracy in the NextDent and Phrozen groups respectively for the material polymer tested. All specimens fell in the clinically acceptable range.

Reprint of: Out-of-sample tests for conditional quantile coverage: An application to Growth-at-Risk

This paper proposes tests for out-of-sample comparisons of interval forecasts based on parametric conditional quantile models. The tests rank the distance between actual and nominal conditional coverage with respect to the set of conditioning variables from all models, for a given loss function. We propose a pairwise test to compare two models for a single predictive interval. The set-up is then extended to a comparison across multiple models and/or intervals. The limiting distribution varies depending on whether models are strictly non-nested or overlapping. In the latter case, degeneracy may occur. We establish the asymptotic validity of wild bootstrap based critical values across all cases. An empirical application to Growth-at-Risk (GaR) uncovers situations in which a richer set of financial indicators are found to outperform a commonly-used benchmark model when predicting downside risk to economic activity.

Reliability of a face scanner in measuring the vertical dimension of occlusion

ObjectiveThis study evaluated the reliability of a face scanner in measuring the vertical dimension of occlusion (VDO). MethodsFully dentate volunteers (n = 20; mean-age = 30.0 ± 10.7 years) were recruited. Clinical facial measurements were obtained using a digital caliper and a face scanner (Obiscanner, Fifthingenium, Italy). The scans were imported into a mesh-processing software, and the distances were measured digitally. Measurements were obtained for each participant with the jaws positioned in maximal intercuspation (MI) and with increased vertical distances of 2, 4, and 6 mm. Vertical and horizontal measures were obtained using facial anatomical landmarks: Glabella (GL), Pronasale (PrN), Subnasale (SbN), inferior border of the right and left Alare, Labiale superius (Ls), right and left Cheilion (Ch), Soft Pogonion (SPg), right and left Tragus of the ear (Tr), for all selected vertical positions. Data analysis included intra-class correlation coefficient (ICC), pairwise comparison tests, Bland-Altman plots, and Passing-Bablok regression. Results120 VDO measurements (clinical=60, digital=60) were recorded by two independent evaluators. Mean differences between digital and clinical measurements ranged from 0.054 ± 0.14 mm to 0.203 ± 0.13 mm. All parameters were strongly correlated (r > 0.93; p < 0.001). ICC estimates revealed excellent reliability, and the measuring procedure yielded the same results on repeated trials irrespective of the raters and measurement methods. Bland-Altman plots revealed a difference, between digital and clinical measurements, of 1.7 % for the vertical measurements. Regression analysis revealed no significant proportional difference between the two methods, so both can be used interchangeably. ConclusionsThe findings of this study demonstrate that VDO can be measured accurately from face scans using 3D mesh-processing software and that even small changes in the VDO could be detected using the digital methods. Clinical SignificanceFindings provide evidence about the reliability of a digital method for jaw relation registrations and may be applied towards incorporating this method into clinical workflows for computer-aided-design/ computer-assisted-manufacturing (CAD-CAM) dentures.

Exploring the perception of small and medium food enterprises in Lincolnshire, UK on the use of front‐of‐pack nutrition labels by consumers

SummaryThe food and drink industry is the UK's largest manufacturing sector, and small to medium‐sized enterprises (SMEs) play a key role in the UK's food system. This study investigates food‐providing SMEs' knowledge of nutrition labels and perceptions of the use of front‐of‐pack nutrition labels in making informed and healthy food choices by consumers. The SMEs were based in Lincolnshire, UK, and comprised food manufacturers (75%), food retailers (14%) and food service providers (11%) (n = 35). A 25‐item questionnaire was developed and validated to collect responses. The questionnaire link was disseminated by email and completed online. Comparisons were made between competing answers using Cochran's Q tests, each with post‐hoc pairwise McNemar test comparisons. Confidence intervals were computed using ordinal regressions. More than half of the SMEs' products (58%) had UK traffic light (TL) colour‐coded schemes and % Guideline Daily Amounts (GDAs). The SMEs stated that the TL label was the best format that provided ‘at‐a‐glance’ information, and this was significantly higher than %GDA and interpretative text (Ps &lt; 0.003). Nearly 49% of the SMEs were unaware of the front‐of‐pack labels being not mandatory in the United Kingdom. Many (86%) acknowledged that the nutrition information on food products was helpful or very helpful for consumers in making purchasing decisions. The SMEs seemed to place the costs of implementing FOP labels on food products above their helpfulness in making healthier food decisions by consumers. This research is one of the first to investigate the perceptions of SMEs on how consumers utilise nutrition labels when making healthier food choices in the United Kingdom. Government subsidies on the costs incurred by incorporating TL labelling on the products are necessary in order to have front of pack (FOP) labels mandatory in the United Kingdom. Greater food industry involvement in academic and policy‐related research is essential to creating a healthier and more sustainable food environment.

Does gentrification precede and follow greening? Evidence about the green gentrification cycle in Los Angeles and Chicago

The health benefits of green space have led to calls for equitable access to parks. When new green spaces are built in low-income communities, however, gentrification often ensues. The “green gentrification” literature has paid little attention to gentrification that might occur before greening. In this paper, we explore whether and under which circumstances gentrification might precede and follow greening, a process known as the “green gentrification cycle.” Focusing on Los Angeles and Chicago, we build hedonic models focused on single-family homes sold in 2010–2021 and run post-hoc pairwise comparison tests to assess price changes over time for homes within a half-mile of new parks (treatment) and farther (control). When considering all new parks, we find that gentrification is associated with subsequent greening and, to some extent, that greening is associated with ensuing gentrification in Los Angeles. In Chicago, gentrification is associated with subsequent greening, but new parks are not associated with ensuing gentrification. Models distinguishing larger regional from smaller non-regional parks show evidence of gentrification before and after non-regional parks were built in Los Angeles, but not for regional parks. In Los Angeles, we identify stronger evidence of gentrification preceding greening farther from downtown than closer to downtown, and signals of gentrification after greening near downtown but not farther away. Models focusing on new parks built near transit stations show inconclusive results. Despite methodological limitations (e.g., examining a single measure of gentrification and different park types together), our findings shed light on the complex spatiotemporal relationships between greening and gentrification.

Diabetes-related hypoglycemia, contributing risk factors, glucagon prescriptions in two community hospitals

IntroductionHypoglycemia has long been recognized as a dangerous adverse effect of the treatment of diabetes mellitus with insulin or insulin secretagogues. ObjectiveOur study was aimed to identify the number of diabetic patients presenting to the emergency department (ED) with hypoglycemia, contributing risk factors for hypoglycemia (including antidiabetic medication regimens), the number of episodes of hypoglycemia requiring medical attention, and how many patients were prescribed glucagon at discharge. Study designOur study is a retrospective analysis across two hospitals from October 2019 to March 2022, including the population of adult persons with diabetes mellitus, above 18 years of age, presenting to the emergency department with hypoglycemia. ResultsOf the women were 2 African Americans, 25 Caucasians, 17 Hispanics, and 39 from other ethnicities. Of the men were 8 African Americans, 32 Caucasians, 27 Hispanics, and 44 from other ethnicities. The mean age of males was 66.2 years, and females was 72.9 years. 131 patients had no prior visits for hypoglycemia. Of the 194 patients, 54 were discharged from the ED, and 140 were admitted to the hospital. The most common risk factors associated with hypoglycemia requiring medical attention were age > 65, having more than one comorbidity, decreased oral intake, and poor socioeconomic status. Regarding recurrent presentations with hypoglycemia, there was a significant association with insulin use (p-value = 0.0007), with a higher-than-expected number of insulin users having a previous visit for hypoglycemia. Only 16.7 % of non-insulin-using patients had prior visits, compared to 40.6 % of insulin users. Pairwise Chi-square testing did not reveal a significant association between any other medication class and prior visits for hypoglycemia, nor was there an association between risk factors and prior visits. To obtain optimal glycemic control, early identification of hypoglycemia risk factors, self-monitoring of blood glucose, and proper selection of anti-diabetic regimens are important to prevent long-term complications. ConclusionUnfortunately, the three elements that would prevent subsequent severe hypoglycemic events (i.e., education, adjustment of medication, and glucagon prescription) are underutilized. Hypoglycemia is more common in the elderly population which remains an unmodifiable risk factor. Identifying patients with persistent poor oral intake is extremely important as they may be prone to hypoglycemic episodes on their current anti-diabetic regimen and will need medication adjustments accordingly. Our future research focuses on whether giving glucagon prescriptions to patients with diabetes mellitus at discharge prevents recurrent ED visits for hypoglycemia.

Modelling Renewable Energy Consumption and Economic Growth in Uganda

This study models renewable energy consumption and economic growth, with evidence from Uganda (1982-2018). The hypothesis that explains causality between renewable energy consumption and economic growth follows the growth, conservation, feedback and neutral. The study uses vector error correction model (VECM) and structural vector auto regression (VAR), within a multivariate data framework. The Pairwise Granger test was specifically used to establish the direction of causality between variables of study. The Johansen co-integration test was carried out to ascertain if there exists a long run relationship between renewable, domestic investment, foreign direct investment and real GDP. The results support the neutral hypothesis between renewable energy consumption and economic growth. The conclusion therefore is a unidirectional relationship running from of renewable energy consumption to economic growth.This paper provides insights into how renewable energy consumption drives economic growth and sustainable development.

Return and Volatility Spillover in Equity and Commodity Market: Some Indian Evidence

This study empirically investigates the return and volatility spillover among equity markets, Agro and non-Agro commodity markets. The study has used daily return data of BSE SENSEX as equity index, MCX iCOMEDEX, including Gold, Silver, and Crude oil, as non-agro indices, and NCDEX (AGRIDEX) as agro commodity indices to analyze volatility transmission between assets and markets using Generalized Autoregressive Conditional Heteroscedasticity (GARCH) and Exponential Generalized Autoregressive Conditional Heteroscedastic (EGARCH) model. The study has used dummy variables in the variance equation to identify the structural breaks during the COVID 19 pandemic. Further, Vector Auto Regression (VAR) pair-wise Granger causality test has been used to understand returns’ causality. The study has found a bidirectional and unidirectional causal relationship between variables. The study indicates that NCDEX could influence all the variables except MCX Gold. In structural breaks with deterministic dummy variables during COVID-19, we have found mixed evidence of asymmetric impact on conditional volatility. The study also indicates a positive and significant asymmetric volatility effect in the case of MCX Gold and MCX Silver during the COVID-19 period. The study has specified that SENSEX dominates the inflow of information to all commodity markets. Also, the findings signpost that information flows from NCDEX to MCX Gold, MCX Silver, and MCX Crude Oil. JEL Codes: C32, E30, E44, F41, G15, Q43

Revisiting the Nexus between Renewable Energy Consumption and Economic Growth in Nigeria: The VECM Approach

The research investigates the effect of renewable energy consumption on economic growth as well as analyzing the dynamic relationship between both variables from 1990 to 2022. Annual secondary data covering the period between 1990 and 2022 were used in the study. Data on real gross domestic product, renewable energy consumption (% of total final energy consumption), gross capital formation (% of GDP), labor force, total and trade (% of GDP) were sourced from World Development Indicator. The study applies Johansen co-integration test and Vector Error Correction Model (VECM) to examine the effect of renewable energy consumption on economic growth and other explanatory variables as well as using pairwise granger causality test to examine the causal relationship between both variables. The empirical evidence revealed long-term relationship between renewable energy consumption and economic growth. Evidence shows that there is no causality either unidirectional or bi-directional between both variables. In short run, renewable energy consumption revealed a significant positive impact on economic growth. This shows that renewable energy may stimulate economic growth, particularly as it has a greater short-term impact on economic growth than capital formation. The key policy implication drawn from the results indicate the need for investment in renewable energy technologies and infrastructure, which can help to increase the availability and affordability of renewable energy, improve workforce development in Nigeria renewable energy sector.

Prognostication for recurrence patterns after curative resection for pancreatic ductal adenocarcinoma.

This study aimed to investigate patterns and factors affecting recurrence after curative resection for pancreatic ductal adenocarcinoma (PDAC). Consecutive patients who underwent curative resection for PDAC (2011-21) and consented to data and tissue collection (Barts Pancreas Tissue Bank) were followed up until May 2023. Clinico-pathological variables were analysed using Cox proportional hazards model. Of 91 people (42 males [46%]; median age, 71 years [range, 43-86 years]) with a median follow-up of 51 months (95% confidence intervals [CIs], 40-61 months), the recurrence rate was 72.5% (n = 66; 12 loco-regional alone, 11 liver alone, 5 lung alone, 3 peritoneal alone, 29 simultaneous loco-regional and distant metastases, and 6 multi-focal distant metastases at first recurrence diagnosis). The median time to recurrence was 8.5 months (95% CI, 6.6-10.5 months). Median survival after recurrence was 5.8 months (95% CI, 4.2-7.3 months). Stratification by recurrence location revealed significant differences in time to recurrence between loco-regional only recurrence (median, 13.6 months; 95% CI, 11.7-15.5 months) and simultaneous loco-regional with distant recurrence (median, 7.5 months; 95% CI, 4.6-10.4 months; p = 0.02, pairwise log-rank test). Significant predictors for recurrence were systemic inflammation index (SII) ≥ 500 (hazard ratio [HR], 4.5; 95% CI, 1.4-14.3), lymph node ratio ≥ 0.33 (HR, 2.8; 95% CI, 1.4-5.8), and adjuvant chemotherapy (HR, 0.4; 95% CI, 0.2-0.7). Timing to loco-regional only recurrence was significantly longer than simultaneous loco-regional with distant recurrence. Significant predictors for recurrence were SII, lymph node ration, and adjuvant chemotherapy.

Developing Phoneme-Grapheme Recognition for English as a Foreign Language: A Longitudinal Study at Japanese Primary School

Foreign language was recently added to Japan's national primary school curriculum. Phoneme-Grapheme Recognition (PGR) skills are a critical step in both L1 and L2 development. Due to its simplistic approach and the lack of new investment in teacher training, research regarding the impact on PGR skills are important. This study tested the relative differences and growth of primary school students' (grades 3, 4, 5, 6) PGR skills across two semesters. Semester-1 (July) and Semester-3 (March) students (n = 256, female n = 130) completed the same PGR test during regular class time. ANOVA and follow-up pairwise tests assessed achievement differences between grades and across the two-semester gap. Difference testing between grades indicated substantial (R2 = .32 &amp; .19) and statistically significant (p &lt; .001) differences at both time points. Pairwise follow-up tests pointed to two steps in statistically different ability (grades 3-4/5-6). Longitudinal tests suggested that the current Japanese national elementary school curriculum supports phoneme-grapheme skill development; However, the two-step ability grouping indicated that the current national curriculum is not sufficiently detailed and/or rigorous to ensure annual student improvement in PGR skills.

Color- and strength-graded zirconia: Strength, light transmission, and composition

Statement of problemNatural teeth are graded in terms of translucency and strength. Graded zirconia materials are now available with a higher yttria content on the top or in the enamel zone to increase surface translucency and a lower yttria content on the bottom or in the dentin zone to increase strength. Such materials could provide multiple advantages over uniform materials and reduce the need for porcelain veneering in anterior artificial crowns; however, studies on the properties of these materials are lacking. PurposeThe purpose of this in vitro study was to measure and compare the biaxial flexural strength, percentage light transmission, elemental content, and phase content of zones within and among color graded zirconia blocks and color- and strength-graded zirconia blocks. Material and methodsDisks of a color graded material (Katana STML) and a strength- and color-graded material (IPS e.max ZirCAD Prime) were fabricated (Zircom Furnace). Biaxial flexural strength was measured using a piston-on-3-ball test in a universal testing machine (n=10). Absolute light transmission was measured with a spectrophotometer. Elemental compositions were quantified for 3 zones in each of the 2 zirconia materials using X-ray fluorescence analysis. Zirconia phase fractions were quantified for 3 zones using X-ray diffraction analysis (XRD). Where appropriate, 2-way ANOVA, 1-way ANOVA, and Tukey multiple pairwise comparison testing were used to determine which of the 6 zones differed from one another (α=.05). ResultsThe color-graded zirconia exhibited gradients in light transmission and differences in phase content in the 3 zones measured. The color- and strength-graded zirconia exhibited gradients in light transmission, biaxial flexural strength, elemental composition, and phase content in the 3 zones measured. The bottom, dentin, or intaglio layer of a strength graded zirconia material was substantially stronger than all other zones of either material (P<.05). The top, enamel, zones of both materials possessed high light transmissibility (P<.05). The 2 materials differed with respect to biaxial strength (P<.001), light transmission (P<.02), elemental composition, and phase composition overall, as well as in most zone-by zone comparisons (P<.05). The performance and composition of the color graded material was consistent with it being a 5Y material throughout. The performance and composition of the color and strength graded material was consistent with it having a 3Y bottom zone and a 5Y top zone. ConclusionsA strength-graded and color-graded zirconia material offers potential advantages in both strength and translucency.

Impact of Patient Education Formats on Treatment Adherence and Denture Hygiene in Edentulous Patients: A Comparative Study.

BACKGROUND Effective communication and patient education are important in geriatric dental care. Memory decline complicates patient adherence. This study aimed to compare verbal, audio, and video patient education material (PEM) and adherence to dental prosthetic management in edentulous patients. MATERIAL AND METHODS 90 completely/partially edentulous patients (aged 40 to 70 years), were divided (simple random) into three groups (Gp) of 30 each . A total of 68 instructions were organized into 9 learning categories. For GpVi, a 20 minute video was shot using a Sony camera (PD170), with two actors depicting related PEM information. Patients were recalled after 1 day and 7days, to recall the PEM instructions. A Denture plaque Index (DPI) determined the efficiency of the instructions at both time intervals. Frequencies, means and standard deviations were derived for each group and then compared using Chi square, paired and unpaired t test and a Neuman-Keul post hoc pairwise test. All significant differences were kept at probability t value of ≤0.05. RESULTS PEM instructions related to patient individuality, proper tongue position and miscellaneous showed poor patient recall. At 1 day interval, audio was found to have better recall than video and verbal in 5 PEM instruction categories. At 7 day interval, video showed better recall than other two groups (P≤0.05). Despite improvements in patients recall, DPI revealed better denture hygiene maintenance in patients receiving instructions through video format (P≤0.05). CONCLUSIONS For all categories, no single media was considered to be sufficient, audio produced early better recall while video influenced long term recall and better denture hygiene maintenance.

Program Directors' Perspectives on Residency Applications in the Post‒United States Medical Licensing Examination Step 1 Era: A Case for Standardized Letters of Recommendation?

The United States Medical Licensing Examination (USMLE) Step 1 test evolved into a key metric utilized by program directors (PDs) in assessing candidates for residency. The transition to a USMLE Step 1 binary pass/fail scoring system has resulted in a loss of an important objective assessment. With national movements toward pass/fail systems for clerkship grading and trends toward abandonment of class ranking, assessing residency applications has become increasingly challenging. The Society of Academic Urologists convened a task force to, in part, assess the perspectives of urology PDs regarding the importance of various aspects of a residency application for predicting clinical performance. An anonymous survey was disseminated to all urology PDs in the US. Perspectives on 11 potential application predictors of clinical performance and demographics were recorded. Descriptive statistics characterized PD responses. Friedman test and pairwise Wilcoxon tests were used to evaluate the relative ranks assigned to application elements by PDs. There was a 60.5% response rate (89/147). Letters of recommendation (LORs) were ranked as the most important predictor, with a mean rank of 2.39, median of 2 (IQR 1-3). Clerkship grades and USMLE Step 1 were comparable and ranked second. Medical school reputation ranked the lowest. There was significant subjective heterogeneity among categories; however, this was less so for LORs, which predominated as the most important factor among application elements (P < .001). To our knowledge, this is the largest sample size assessing PD perspectives on application factors that predict clinical performance. The second (clerkship grades) and third (USLME Step 1) most important factors moving toward binary pass/fail systems create an opportunity for actionable change to improve assessment objectivity. Our data demonstrate LORs to be the most important factor of residency applications, making a compelling argument for moving toward a standardized LOR to maximize this tool, mitigate bias, and improve interreviewer reliability.

Influence of visceral manipulation on hormonal profile in women with polycystic ovarian syndrome: A randomized trial

Background. Polycystic ovary syndrome (PCOS) is the most common endocrine condition in women of reproductive age and has been suggested as a risk factor for cardiometabolic disease. Depending on which diagnostic criteria are applied, approximately 10–15% of the women of reproductive age are affected by PCOS.Objective. To examine how viscera manipulation Influences hormonal profile in women with PCO. Design. A prospective randomized single-blind controlled trial. Setting. Outpatient clinics of Sadat General Hospital. Methods. Thirty patients of PCO females were recruited and randomized into two equal groups: the control group received a diet guidelines therapy in the form of the hypocaloric Mediterranean diet for 12 weeks, and the study group received the same control group interventions in addition to visceral manipulation (VM). biochemical analysis (FSH &amp; LH) and BMI was the primary outcome. All variables were measured at the baseline and after 12 weeks of the intervention. Results. Statistical analysis was done by using paired’ test which showed significant improvement in both groups. Therefore, using mixed design MANOVA and multiple pairwise comparison tests (Post hoc tests) for the BMI and LH/FSH ratio post-treatment revealed that there were significant decreases in LH/FSH ratio (p =0.007) in favor to group B when compared with group A, with no significant differences in BMI between both groups (p = 0.443), showing that VM group (B) is more effective than group (A) on biochemical analysis (p &lt; 0.05). Conclusion. Using visceral manipulation with a standard program of hypocaloric Mediterranean diet has more beneficial effects on hormonal profile in women with PCO.

The impact of ovarian stimulation on the human endometrial microenvironment.

How does ovarian stimulation (OS), which is used to mature multiple oocytes for ART procedures, impact the principal cellular compartments and transcriptome of the human endometrium in the periovulatory and mid-secretory phases? During the mid-secretory window of implantation, OS alters the abundance of endometrial immune cells, whereas during the periovulatory period, OS substantially changes the endometrial transcriptome and impacts both endometrial glandular and immune cells. Pregnancies conceived in an OS cycle are at risk of complications reflective of abnormal placentation and placental function. OS can alter endometrial gene expression and immune cell populations. How OS impacts the glandular, stromal, immune, and vascular compartments of the endometrium, in the periovulatory period as compared to the window of implantation, is unknown. This prospective cohort study carried out between 2020 and 2022 included 25 subjects undergoing OS and 25 subjects in natural menstrual cycles. Endometrial biopsies were performed in the proliferative, periovulatory, and mid-secretory phases. Blood samples were processed to determine serum estradiol and progesterone levels. Both the endometrial transcriptome and the principal cellular compartments of the endometrium, including glands, stroma, immune, and vasculature, were evaluated by examining endometrial dating, differential gene expression, protein expression, cell populations, and the three-dimensional structure in endometrial tissue. Mann-Whitney U tests, unpaired t-tests or one-way ANOVA and pairwise multiple comparison tests were used to statistically evaluate differences. In the periovulatory period, OS induced high levels of differential gene expression, glandular-stromal dyssynchrony, and an increase in both glandular epithelial volume and the frequency of endometrial monocytes/macrophages. In the window of implantation during the mid-secretory phase, OS induced changes in endometrial immune cells, with a greater frequency of B cells and a lower frequency of CD4 effector T cells. The data underlying this article have been uploaded to the Genome Expression Omnibus/National Center for Biotechnology Information with accession number GSE220044. A limited number of subjects were included in this study, although the subjects within each group, natural cycle or OS, were homogenous in their clinical characteristics. The number of subjects utilized was sufficient to identify significant differences; however, with a larger number of subjects and additional power, we may detect additional differences. Another limitation of the study is that proliferative phase biopsies were collected in natural cycles, but not in OS cycles. Given that the OS cycle subjects did not have known endometrial factor infertility, and the comparisons involved subjects who had a similar and robust response to stimulation, the findings are generalizable to women with a normal response to OS. OS substantially altered the periovulatory phase endometrium, with fewer transcriptomic and cell type-specific changes in the mid-secretory phase. Our findings show that after OS, the endometrial microenvironment in the window of implantation possesses many more similarities to that of a natural cycle than does the periovulatory endometrium. Further investigation of the immune compartment and the functional significance of this cellular compartment under OS conditions is warranted. Research reported in this publication was supported by the National Institute of Allergy and Infectious Diseases (R01AI148695 to A.M.B. and N.C.D.), Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01HD109152 to R.A.), and the March of Dimes (5-FY20-209 to R.A.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or March of Dimes. All authors declare no conflict of interest.

Nexus between Resource Utilization and Environmental Pollution: Evidence from 23 Countries in Africa

As Africa becomes more open to trade and globalization, emissions in the region continue to increase steadily. In the context of the prevailing economic and political conditions in Africa, it is anticipated that climate change shocks will impede developmental progress and hinder economic growth within the region. This research endeavors to empirically investigate the interconnections among GDP per capita, renewable energy consumption, freshwater withdrawals, forest area, and greenhouse gas emissions across 23 African nations from 2001 to 2020. The analytical framework incorporates the Pedroni cointegration test and the Fully Modified Ordinary Least Squares (FMOLS) method to establish a durable relationship among the variables under scrutiny.&#x0D; The outcomes of our investigation disclose that a 1% escalation in GDP per capita and freshwater withdrawals corresponds to an 87.75% and 16.93% increase in greenhouse gas emissions, respectively. Conversely, a 1% rise in renewable energy consumption and forest area manifests a decline in greenhouse gas emissions by 58.51% and 13.24%, respectively. The examination reveals a negative coefficient for GDP per capita squared, affirming the validity of the Environmental Kuznets Curve (EKC) hypothesis. Furthermore, the Pairwise causality test indicates bidirectional causation between renewable energy consumption and greenhouse gas emissions and between renewable energy consumption and GDP per capita. Additionally, unidirectional causality exists from GDP per capita to greenhouse gas emissions, freshwater withdrawals to GDP per capita, forest area to GDP per capita, and freshwater withdrawals to forest area. The study recommends the sustainable use of resources in order to achieve low emissions.

Pilot study: A simple CAD-based tool to detect breast cancer on MRI of the breast

PurposeThis pilot-study aims to assess, whether quantitatively assessed enhancing breast tissue as a percentage of the entire breast volume can serve as an indicator of breast cancer at breast MRI and whether the contrast-agent employed affects diagnostic efficacy. MaterialsThis retrospective IRB-approved study, included 39 consecutive patients, that underwent two subsequent breast MRI exams for suspicious findings at conventional imaging with 0.1 mmol/kg gadobenic and gadoteric acid. Two independent readers, blinded to the histopathological outcome, assessed unenhanced and early post-contrast images using computer-assisted software (Brevis, Siemens Healthcare). Diagnostic performance was statistically determined for percentage of ipsilateral voxel volume enhancement and for percentage of contralateral enhancing voxel volume subtracted from ipsilateral enhancing voxel volume after crosstabulation with the dichotomized histological outcome (benign/malignant). ResultsIpsilateral enhancing voxel volume versus histopathological outcome resulted in an AUC of 0.707 and 0.687 for gadobenic acid, reader 1 and 2, respectively and in an AUC of 0.778 and 0.773 for gadoteric acid, reader 1 and 2, respectively. Accounting for background parenchymal enhancement by subtracting contralateral enhancing volume from ipsilateral enhancing voxel volume versus histolopathological outcome resulted in an AUC of 0.793 and 0.843 for gadobenic acid, reader 1 and 2, respectively and in an AUC of 0.692 and 0.662 for gadoteric acid, reader 1 and 2, respectively. Pairwise testing yielded no statistically significant difference both between readers and between contrast agents employed (p > 0.05). ConclusionOur proposed CAD algorithm, which quantitatively assesses enhancing breast tissue as a percentage of the entire breast volume, allows indicating the presence of breast cancer.