It is also well-known that teacher stress contributes to more violence against students. However, little is known about personal and school context factors that contribute to teachers’ stress. The current study examined whether, in addition to school-related factors, job perceptions, including the feeling of pressure at work and perceived school climate and teaching difficulties, contribute to teachers’ stress. (2) Methods: A representative sample of 291 teachers from 12 public secondary schools in southwestern Uganda responded to self-administered questionnaires. (3) Results: Teaching difficulties and feelings of pressure at work contributed to teachers’ stress. Furthermore, stress did not vary with teachers’ sociodemographic variables. (4) Conclusions: Teachers’ perceptions of their working conditions were associated with teacher stress levels. Therefore, more efforts need to be geared towards improving the working conditions of teachers as a way of reducing stress. Teaching is a highly stressful profession, and the characteristics of teachers’ work seem to be related to stress and associated negative emotions . The teaIn low-income countries, teachers are further burdened with often poor working conditions, and these terms and conditions of service may result in stress. For example, teachers interact and work with students daily, but, in addition, they have to take over multiple other tasks and roles in the school, such as teaching, being a class teacher, being a sports or career guidance master, and being the head of a department, that altogether increases their workload . More soA nexus of teacher personal attributes, such as age, as well as contextual and environmental factors, including school and class size , may altTeacher stress has negative consequences for the individual teachers, such as mental health and psychological problems , and theTeachers in Sub-Saharan Africa work in demanding and nerve-racking situations that are likely to increase their stress levels. For example, underpaid teachers experience difficulties maintaining discipline in large classes with a high teacher to student ratio . Among TThe levels of stress experienced by teachers also varied with individual attributes. Female teachers ,20 who wAs increased stress levels are associated with negative outcomes, stress management techniques have been suggested as an essential part of teacher training efforts . TherefoTeaching is considered as a stressful vocation ,3,4,8,15The education system in Uganda takes on the 7-6-3 model, with seven years of primary education, six years of secondary education (four years of ordinary level or lower secondary and two years of advanced level or upper secondary), and 3–5 years of tertiary education. The study was conducted in the Ankole region of southwestern Uganda, with 3254 teachers  employed in the 103 government-aided secondary schools and with a student enrollment of 61,825 and an equal number of male and female students .The study was conducted in six of the 10 districts of the Ankole region in southwestern Uganda from April to November 2017. The region had a total of 41 public secondary schools with a student enrollment of at least 360 and about 15 teachers. We randomly selected five districts and added one district with the largest population in the region. Then, from each district, we randomly selected two government-aided secondary schools, resulting in a sample of 12 schools. In total, all of the 435 teachers employed at these schools were eligible to participate in this study.Ethical approval for the study was obtained from the Uganda National Council of Science and Technology (UNCST: SS 4032), the Research Ethics Committee of Mbarara University of Science and Technology (MUST REC 15/10-15), Uganda, and the Ethical Review Board of the University of Konstanz, Germany (35/2016). Before the start of the study, one Ugandan researcher (J.S.) and two trained research assistants visited all of the selected schools and discussed the relevant study details with the school administration and teachers as a way of eliciting their collaboration during the study. Before participating, teachers signed an informed consent document and then responded to the anonymous self-report questionnaire for about 20–30 min. In total, 291 of the 435 eligible teachers participated in the study (response rate: 67%).SD = 8.79, range: 0.42–43.75, median: 11 years). Most teachers (71.1%) were bachelor’s degree holders, who spent on average 42.69 h per week  at the school, teaching an average of 68 students (SD = 46.70). Teachers (54.5%) had additional sources of income, including other jobs and owning businesses.The participating teachers  were in the age range between 23 and 59 years  and had a mean teaching experience of 12.67 years   that hasThe 19-item Copenhagen Burnout Inventory (CBI) with three subscales that are work-related (α = 0.87), client-related (α = 0.85), and personal burnout (α = 0.87) assessed teacher’s stress levels and burnout . Items aPearson correlation coefficients were used to determine associations among the study variables. Regression analysis was used to examine the predictors of stress among teachers. All requirements for a multiple regression analysis were fulfilled. The independent variables were not a combination of other variables, hence satisfying the assumption of singularity. We did not need to take multicollinearity into account, as the tolerance was less than one, and the variance inflation factor did not exceed 1.15. Neither univariate nor multivariate outliers were detected. The plots of standardized residuals and scatter plots revealed that the data satisfied the assumptions of normality, linearity, and homoscedasticity. Data were analyzed with IBM SPSS statistics 26 .M = 13.37, SD = 4.53, range: 3–22) that arose from several factors . On the other hand, teachers reported on the atmosphere at school and their perceived teaching difficulties regarding the teaching profession , for instance, not feeling competent in the subject taught (94%), becoming involved in the personal lives of their students (85.2%), and organizing the classroom for instruction (52.6%).Teachers experienced feelings of pressure in their working context  in diverse aspects of their work. Likewise, a majority of them (59%) reported work-related stress , while 51% of the teachers experienced student-related stress  .The majority of teachers (60.2%) experienced elevated or high levels of stress (100) see . Further= 0.145) were all related to teachers’ stress.In In the current study, we investigated teachers’ personal and school-related factors that may contribute to elevated levels of stress. Our results indicated that a majority of teachers (60.2%) experienced elevated and high levels of stress, and that higher levels of stress were associated with the use of violence. Furthermore, work-related stress and student-related stress were associated with the use of violence see . Many teIn line with our hypothesis, the perceived feelings of pressure at work, negative school climate, and teaching difficulties were significantly associated with teachers’ stress. Thus, teacher-related school environment factors contributed to teachers’ stress. Our findings converge with previous studies that discussed how stressful working conditions in Sub-Saharan African and Asian schools resulted in increased teachers’ stress ,7,23. InOur results shed light on the diverse sources of stress teachers experience that put them under pressure during the execution of their tasks. Most of the time, these are external stressors, such as the implementation of a new curriculum at lower secondary schools without the adequate training of the few available teachers, and little appreciation of the services of dedicated teachers by the public. Teachers’ struggles and concerns with their work and life balance may affect their class duties in a resource-limited education sector . Our finFurthermore, in the present study, feelings of pressure were greater for male teachers than for female teachers. This may be explained to some extent by the sample characteristics. The present study sample consisted of mainly male teachers (over 75%). In Uganda, male teachers have the responsibility of taking care of their families. In many cases, they had to engage in supplementary income-generating activities, like owning businesses, that have the potential of compromising their teaching duties.Our findings were not in line with other studies that reported associations between teachers’ stress and demographic variables, such as age, family size, and socioeconomic status ,20,21,22Our findings indicate that demanding working conditions are related to increased stress among teachers and the subsequent use of violent discipline. Therefore, teacher training institutions need to educate prospective teachers on the realities of the teaching profession. Teacher trainees need to be updated on the pros and cons of the teaching profession. Trainees need to be adequately equipped with skills for managing stress, self-care, multitasking, and classroom management techniques. In so doing, trainees will be ready to work effectively in a challenging work environment that is devoid of the necessary resources during their practicum and after they have qualified as professional teachers.In examining the personal and work-related factors that are related to increased teachers’ stress levels, our study provides a basis for targeted interventions that can, in the short-term, reduce teacher stress, while, in the long-term, decrease the use of violent discipline ,8. Our rTeachers’ stress can also be reduced by improved social support from supervisors and professional networks, appreciation of their contribution by society, and seeking their input when formulating policies that affect their work. Such strategies can easily be implemented at the interpersonal level and school level.Our study investigated the associations between working conditions and increased stress levels among teachers. However, our findings need to be replicated in longitudinal studies with larger samples to get a better understanding of how diverse work-related factors result in increased stress. Likewise, further research should examine other factors that contribute to heightened stress, including personal factors, such as past violence exposure, mental health, and attitudes towards violence. With a better understanding of the factors that cause stress among teachers in the school setting, we can refine interventions that reduce stress.Our study adds more knowledge to the relation between the school context and teachers’ stress. With a large representative sample of teachers from 12 public secondary schools from southwestern Uganda, our findings can be generalized to the public secondary schools in that region. The measures used in the study have been used in East Africa before. However, some limitations need to be noted. First, the cross-sectional study design does not allow for the establishment of causality. However, the results are consistent with prior studies that established relationships between work conditions and teachers’ stress. Secondly, the use of self-reports is prone to bias and social desirability. Furthermore, the fact that our model only predicted 17% of the variability of teachers’ stress levels implies that other factors may explain teachers’ stress that we did not include in this study.Our results indicate that teachers’ perception of their working conditions, but not their personal characteristics, are related to teachers’ stress levels. As teachers’ stress levels are related to negative educational outcomes, more efforts need to be geared towards improving the working conditions of secondary school teachers as a way of reducing stress. Teachers also require training in stress management techniques, self-care, and alternative disciplinary strategies.


The last few years have seen increasing research on self-report measures of compassion. The Compassionate Engagement and Action Scale (CEAS) is rooted in an evolutionary approach to compassion, which focuses on the competencies of compassion those are engagement with distress or suffering, and taking action to alleviate and prevent it. This study sought to validate the CEAS in a Japanese population using a cross-sectional design. A total of 279 students  answered self-report questionnaires, including the Japanese version of CEAS. We found single-factor structures for compassion for others scales, compassion from others scales, and compassion for self scales. All scales were found to have acceptable internal consistency, test-retest reliability, content validity, and construct validity. Even though some limitations, these results indicate that the Japanese version of CEAS is an adequately constructed and useful measure to assess compassionate engagement and action toward others, from others, and for the self with Japanese population. The last 20 years have seen an upsurge of interest in prosocial behaviour and in particular compassion, with evidence that it has powerful physiological effects and aids in emotion regulation and moral behaviour –5. To daAnother recently developed measure is rooted in the evolutionary model of compassion, for the therapy. This is the Compassionate Engagement and Action Scales (CEAS). The CEAS is based on the idea that all motives have a stimulus response algorithm underpinning them. Since compassion evolved from mammalian parental caring behaviour the algorithm is sensitivity to the needs and suffering of the infant associated with taking action to do something about. Hence this is the root of the evolutionary approach, compassion has considerable overlaps with Buddhist approaches and supports a definition of “sensitivity to suffering in self and others with a commitment to try to alleviate and prevent it” .Thus, thHence the scale includes items that are linked to being able to engage with distress and suffering (such as being sensitive to distress), and items for taking action to alleviate and prevent distress and suffering (such as thinking about how to be helpful). In addition, as compassion is a social process, it can be seen as a social flow in three orientations that can permeate interactions. Hence, i) there is the compassion we can feel for and direct at other people, ii) there is the compassion from others that we are aware of and respond to and iii) there is the compassion that we can bring to our own state of suffering and difficulty. Consequently the CEAS has three separate scales measuring these flows. Considering these three flows enables us to evaluate compassion from multilateral way including interactions between giving, and receiving compassion .In original research on the CEAS, compassion for others has positive small correlation with positive aspect of self-compassion which is a well-known another concept related to compassion, while negative small correlation with negative aspect of self-compassion . FurtherFrom the perspective of convergent validity, compassion for others includes noticing distress signals or indicators of suffering, and empathic connection with the suffering of others . FurtherAdditionally, not only noticing, compassion for others also requires commitment, action for alleviation of distress, and consideration for how to do it . TherefoIn original research on CEAS, being open and receptive to compassion from others has also small to medium correlations with positive aspect of self-compassion, self-reassure, compassionate love, and compassionate goal . AdditioFrom the perspective of convergent validity, compassion from others includes experiences or feelings that people around us are supportive when we need their help : it is aIn original research on CEAS, compassion for self has positive large correlations with positive aspect of self-compassion, and negative small correlation with the negative aspect of self-compassion . FurtherPrevious report found that compassion for self has negative small to medium correlations with traumatic qualities of shame memories, depression, centrality of shame memories, and positive medium correlations with early memories of warmth, and positive with safe affect . AnotherAdditionally, from the perspective of coping, compassion for self requires acceptance for own distress, and action for alleviation of it including plan what to do in stressed situations . Thus weFrom the perspective of discriminant validity, substance use is thought to be an adequate indicator for the CEAS. A previous survey has shown that alcohol use correlate to prosocial behaviour slightly which thought to be a concept reflecting behavioural aspect of compassion for others . On compAs mentioned above, some researches purport that the function of compassion and CEAS is a factor related to mental wellness, but each scale’s origins stem from different concepts. The CEAS, however, does not originate in Asia, and thus may not be representative of compassion in this region, at least for the scale of fears for compassion, suggesting there may a different CEAS structure be used for Asian samples . CompassEthicality was maintained by following principles outlines in the Declaration of Helsinki, and the required ethics committee of Chiba University approved the study (No. 2478).Participants were recruited into the study at four Japanese universities without knowledge of compassion’s psychological concept. The survey was conducted following the class of introductory psychology with paper-based questionnaire. Informed consent was provided on the face-sheet of the questionnaire, as was the purpose of the study. Written consent was not obtained in order to maintain confidentiality and anonymity of participants; instead, participants were asked to only respond to the questions posed to them if they agreed to participate in the study. After responding, participants placed questionnaire in the box. To verify the test-retest reliability, students from two universities (of the four) were recruited again in the same class. To match the data, participants were requested to answer the same four digit numbers as what they had created at the first survey. The Chiba University Ethics Committee approved the procedures.A total of 279 students  participated in the first survey. The mean age was 19.35 (SD = 3.26) years old. Of these, 144  participants responded to the second survey to evaluating test-retest reliability. The mean age of the second survey participants was 19.80 (SD = 1.80) years old. About marital state, 245 students answered single, no one answered married, and 24 students were unknown (0.09%). In test-retest measurement, 137 students answered single, no one answered married, and 7 students were unknown (0.04%).Measurements used were the Compassionate Engagement and Action Scales–Japanese version (CEAS-J), the Japanese version of a Self-Compassion Scale—Short Form (SCS-J-SF) , DepressIn translation of CEAS, we followed preceding guidelines in order to comply with cross-cultural validity . At firsNext, the CEAS Japanese version was reviewed by an English psychologist working for a translation agency and was translated back into English. The authors  of both the original version of the CEAS and the Portuguese version (CEAS-P) verified the accuracy of the new version. This translation then received feedback from the previous check into consideration from the original authors, and the manuscript was translated into Japanese once again and examined for content validity. This final step was performed by KA and YM, a clinical psychologist with a PhD awarded in Australia and a Japanese teaching certification. Once the original authors of the CEAS and the Portuguese version reviewed the CEAS-J, questions and modification requests arose for back-translation. It was concluded with the authors of the Japanese version that the concerns related to differences of idiom between the languages of English and Japanese. Thus, we did not alter the Japanese version in this round.Third, to confirm comprehensibility, 18 undergraduate students responded the CEAS-J and were instructed to address concerns about the questions in the Japanese version, and to identify any areas of difficulty in finishing the draft version. As a result, all students did not suggest amendments or raise concerns within the CEAS-J.The CEAS-J consists of 10 items, where six assess engagement, and four assess actions of compassion on each dimension . Participants were presented with a written description of compassion , and werThe SCS consists of 26 items, and which is composed of 6 subscales on a Likert scale of 1  to 5 . As noted above, the SCS is the most popular instrument to measure self-compassion by Neff . The shoThe DASS-15 is the Japanese version of the DASS-21, the condensed version of the Depression Anxiety Stress Scales  32]. Th. Th32]. The Satisfaction With Life Scale (SWLS) is a measurement that assesses life satisfaction as a part of subjective well-being . The JapThe OOER, from the Multidimensional Empathy Scale (MES), was developed to assess individual differences of empathy . The MESThe Brief-COPE is a questionnaire used to evaluate coping style and has been translated into Japanese  34]. Te. Te34]. Substance use reflects the tendency to use alcohol or drug to distract from problems; thus, it will be used as indicator of discriminant validity for three scales.Three-week test-retest reliability was analysed using the Global Rating of Change (GRC) assessment recommended in guideline . On a LiAnalysis was conducted using R version 3.2.3 . MissingWe conducted minimum average partial (MAP) which helps to determine the number of factors objectively . Next, wTo evaluate internal consistency, the scores of Cronbach’s αwere calculated. In test-retest reliability, we excluded participants with a change in GRC; only data from people who scored from 3 to 5 (regarded as ‘no change’) were analysed. After that, intra-class correlations were calculated.To evaluate convergent, and discriminant validity, Pearson’s correlation coefficient was calculated. We interpreted the effect size r based on previous guidelines, ≧.10 as small, ≧.30 as medium, and ≧.50 as large .We hypothesised that compassion for others has large correlation with OOER (r ≧ .50), and medium correlation with active coping, and acceptance (.30 ≦ r < .50). For compassion from others, it has large correlation with use of emotional support, and instrumental support (r ≧ .50). For compassion for self, it has large correlation with positive aspect of SCS (r ≧ .50), and medium with active coping, positive reframing, planning, acceptance positively (.30 ≦ r < .50), and denial, behavioural disengagement, and self-blame (-.30 ≧ r > -.50).Following to original version, relations to mental health  were verified by using Pearson’s correlation coefficient.About missing value, nine students out of 279 students were incomplete (0.03%). In test-retest measurement, seven students out of 144 students were incomplete (0.04%). All of missing values were imputed using multiple imputation as mentioned in data analysis section.The results of MAP suggested a single factor structures on three scales with the smallest average squared correlation of .326, .325, .0411 in compassion for others, .325, .518, .676 in compassion from others, and .411, .521, .620 in compassion for self. Next, we conducted EFA with maximum likelihood method on each scales with single factor structures.On compassion for others scale, an item  showed low factor loading (less than .40) and removed. The final factor structure revealed by the exploratory factor analysis, as well as the mean, standard deviation, skewness, and kurtosis of each item, are shown in On compassion from others scale, all items showed sufficient loadings with single factor. The final factor structure revealed by the exploratory factor analysis, as well as the mean, standard deviation, skewness, and kurtosis of each item, are shown in On compassion for self scale, three items were deleted because of low factor loadings (less than .40). They were “I am accepting, non-critical and non-judgemental of my feelings of distress”, “I am emotionally moved by my distressed feelings or situations”, and “I notice, and am sensitive to my distressed feelings when they arise in me”. The final factor structure revealed by the exploratory factor analysis, as well as the mean, standard deviation, skewness, and kurtosis of each item, are shown in α of all variables are shown in Descriptive statistics and Cronbach’s To evaluate test-retest reliability, intraclass correlations were calculated for participants whose answers were in the accepted level of 3 to 5 in the GRC. One hundred forty-four of 163 participants answered in this range, and the mean age was 19.80 (SD = 1.80). Intraclass correlations of compassion for others scale were .67 (0.57–0.76); for compassion from others scale, correlations were .72 (0.63–0.79); and for compassion for self scale, correlations were .68 (0.58–0.76).Correlations of all variables are shown in About convergent validity, compassion for others showed large correlation with OOER (r = .67), and medium correlations with active coping (r = .32), and acceptance (r = .33). Compassion from others and use of emotional support (r = .51), and use of instrumental support (r = .50). Compassion for self showed medium correlation with positive aspect of self-compassion (r = .40), active coping (r = .40), denial (r = -.30), behavioural disengagement (r = -.33), positive reframing (r = .35), planning (r = .43), and acceptance (r = .33). Lastly, compassion for self correlated with self-blame (r = -.15) modestly.On mental health, compassion for others did not correlate with depression, anxiety, stress, nor SWSL. Compassion from others correlated to depression (r = -.21), anxiety (r = -.14), and SWSL (r = .27) modestly. Compassion for self correlated with depression (r = -.30) mediumly, and anxiety (r = -.19), stress (r = -.15), and SWSL (r = .26) modestly.This study sought to develop a Japanese version of the CEAS. As an accepted recommendation of Beaton and colleagues, translation procedures used two translations independent of one another . Scales All scales were suggested single-factor structure by MAP, and some items deleted on compassion for others, and compassion for self scales. Although the identification of compassion on the CEAS includes sensitivity and commitment, which were shown as engagement and action subscales separately, they were integrated into higher-order factor in the original scale . A reporAdditionally in compassion for others scale, an item which is“I am emotionally moved by expressions of distress in others” was removed because of low factor loading. Similar item in compassion for self scale  is also removed as with another item on compassion for self . These items seemed to be describing own emotional response directly, and might be caused by the cultural differences in attitude toward own emotional response. In Eastern countries, low arousal emotions are valued more than high arousal emotions , and alsNext, an item showing non-critical attitude  was removed on compassion for self. Previous research shows that self-criticism is higher in Japanese individuals than individuals in other twelve countries . EarlierThe internal consistencies on the original version of CEAS were from 72. to .94 and were from 84. to .92 in the CEAS-J, indicating that the CEAS-J has enough internal consistency as original version. Intra-class correlations of test-retest reliability were found to be sufficient (from .67 to .72.) in a three-week interval, and it is believed that the CEAS-J has acceptable test-retest reliability.Most of hypotheses were supported on construct validity except for positive aspect of SCS, and self-blame on compassion for self.Compassion for others showed large correlation with OOER, and medium correlation with active coping, and acceptance. Compassion from others showed large correlation with use of emotional support, and use of instrumental support. Thus we can conclude that these scales have enough construct validity.Meanwhile, compassion for self showed lower correlation with positive aspect of SCS and self-blame, while it showed enough correlations with active coping, denial, behavioural disengagement, positive reframing, planning, and acceptance. In relation to positive aspect of SCS, we can assume that smaller effect size might be caused by using the short-form version of SCS31]. We . We 31].In relation to mental health, compassion for others showed correlation with satisfaction with life, but no relation to depression, anxiety, and stress in the original version . HoweverCompassion from others showed small correlation with depression and stress, and medium with satisfaction with life . This reAbout compassion for self, it showed small correlation with depression, anxiety, and stress, and medium with satisfaction with life in the original research . SimilarThe main strength of this study was the ability to successfully develop a Japanese version of the CEAS. The CEAS-J can be considered a useful measurement to reveal the functions of compassion from the evolutional perspective. As mentioned earlier, there are several discussions about the specific functions of compassion and self-compassion, therefore by revealing the relationships among compassion, self-criticism, and mental well-being, more meaningful treatment can be developed to help preventing mental illness in Japanese society.In compassion focused therapy, when patients have difficulty developing compassion for self, therapists often work with the client on understanding compassion for and from others . On thatα: we need to consider it in interpretation.There are limitations to this study. We sampled only 279 Japanese undergraduate students since in the development of the CEAS, even though undergraduate students were recruited from three countries in the original study  . HoweverIn this study, we developed the CEAS-J based on guidelines to ensure reliability and validity by the authors of the CEAS. The results indicated different factor structure to its original version. The tests of internal consistency, test-retest reliability proved sufficient. Though some relations differed from original versions, construct validities were acceptable, and the relations between variables were identified. We can conclude that the CEAS-J has enough reliability and validity, and future studies need to reveal more detail about reproducibility and the functions of compassion with other populations.S1 File(DOCX)Click here for additional data file.S2 File(XLSX)Click here for additional data file.


Vertical alveolar osteogenesis distraction (VAOD) technique appears to provide the best results in terms of vertical bone gain. Before its use in humans, most devices are tested on experimental animals. Currently, there is no consensus on which is the ideal biological animal model for VAOD studies. In this review, it has been found that the animal model influences the results. In addition, the most used, easier to handle, and with less complications was the Mongrel dog. The use of pigs and minipigs, given their difficult handling and poor hygiene, is not recommended.This study is aimed at synthesizing all available evidence on vertical alveolar osteogenesis distraction (VAOD) in animal trials to determine whether the animal model used and its handling influence or not, and find which is the most appropriate animal model for this specific technique. This systematic review has been carried out following the PRISMA statements. Bibliographic sources have been consulted manually by two reviewers. Risk of bias was assessed using a version of the Newcastle-Ottawa-Scale (NOS). The selection criteria established by expert researchers were applied in order to decide which studies should be included in the review. Twenty-six studies met the inclusion criteria and were included in the review. Twenty-four of them had a high quality (score between 7 and 9), two medium quality (score between 4 and 6), and none low quality (score between 1 and 3). The highest possible score was 9 (using the NOS). Six studies complied with all NOS criteria. The animal model has been seen to influence the results, leading to failure in some cases. The most used animal model on VAOD, with fewer complications, was the Mongrel dog. The use of the pig and minipig is not recommended, due to the difficulties in handling and complications encountered. In oral implantology, one of the most common challenges is the deficiency of mandibular or maxillary alveolar bone height or width. The causes of bone loss include pathological processes such as trauma, periodontal disease, tumor resections, and congenital malformations .Currently, the available techniques that allow the use of long implants without reducing the vertical size of the crown are: augmentation of the floor of the maxillary sinus, the placement of pterygoid implants, and dental nerve transposition . To modiThe biological basis of osteogenic distraction (OD) is called callotasis (etymology: tasis = elongation), which is the progressive elongation of the callus formed around bony portions created by the osteotomy. This elongation process is progressive, allowing for the preservation of the bloodstream. The bone regeneration mechanism is made up of two procedures: histogenesis  and osteogenesis  .The OD technique involves the following phases: (A) surgery, (B) latency, (C) distraction, and (D) consolidation. The distraction period includes two different phenomena: the distraction frequency (which is the amount of distraction activations that are performed per day) and the distraction rate  .The vertical alveolar osteogenesis distraction (VAOD) procedure is an effective remedy for soft tissue and bone formation in boneless areas which hinder the rehabilitation with dental implant ,3. On thBerhard von Langenbeck carried out, in 1869, the first experimental research on long bone distraction. The fist studies on oral distraction were conducted in 1927 by Rosenthal . In viewWe can differentiate between two types of distraction gadgets: extraosseous and intraosseous. Depending on their role, there is also a distinction between distractor-implants and distractors . FinallyIn a systematic review, Esposito et al.  did not ‑No donor site morbidity.‑Simplest procedure.‑Graft resorption less chance.‑The quantity gained is more predictable.‑The rate of infection and bone resorption is lower‑Most of complications are minor.‑Possibility of implant placement in the transported fragment.‑The consolidation period is shorter, so the treatment has a shorter duration.‑When the results are not satisfactory, complementary techniques can be used.Compared to other tissue augmentation treatments, the distraction technique has several advantages :‑No donoHowever, it also presents a series of possible disadvantages  6,7].,7.6,7].Nonetheless, OD has achieved a certain level of application in maxillofacial and implant surgery as a technique for alveolar bone augmentation. However, there is still no consensus on which is the ideal animal biological model for vertical bone distraction assessment. For the experimental evaluation of alveolar distraction, we need a suitable biological model. This model should offer an adequate amount of bone for the device to be placed on, and subsequently design distraction devices for clinical use in humans. Tests for mandibular alveolar distraction have been developed in small animals, such as rats or rabbits, and in medium and large animals, such as dogs, sheep, minipigs, goats, and primates. Nonhuman primates could represent the ideal biological model for the VAOD research. However, its high cost, the ethical concerns, and difficult handling make it almost not feasible. Currently, the selection of an animal biological model for VAOD is still undefined .This study is aimed at collecting all available evidence on VAOD studies in animals to determine whether the animal model used and its handling influence or not, and find which is the most appropriate animal model for VAOD studies.This systematic review has been carried out following the PRISMA statements . Ethics The selection criteria incorporated permutations of the following terms: “Alveolar vertical distraction”, “dental implant”, “animal model”, “biological model”, “alveolar ridge”, “vertical alveolar ridge distraction”, “distraction osteogenesis”, “alveolar ridge augmentation”, “alveolar bone loss”, “atrophic jaws”.PICO methodology. Animal models (P = patients), experimental studies (I = intervention), of different species (C = comparison), used for VAOD (O = result). PICO question: What is the most appropriate animal model to use in VAOD experimental studies?Experimental studies of alveolar bone distraction aimed at vertical augmentation.Animals used as biological models.Articles in English.Eligibility criteria. The studies have been selected according to the following pattern:Quality assessment. We used a version of the Newcastle-Ottawa Scale (NOS) to evaluate the quality of the studies with a maximum of 9 stars. Within the analysis, the studies were defined as low quality (1–3), medium quality (4–6), or high quality (7–9). The quality of the studies was assessed in duplicate and independently by two reviewers (M.G.-G and F.M.).Analysis and extraction of parameters of interest. The studies were evaluated by analyzing the following items: number of animals used (patient number), age, weight, distractor details, number of distractors used, number of distraction segments, location of the distractor (jaw/maxilla and segment site), distraction succession , rate and frequency of distraction, vertical bone gain obtained at the end of the study, specification of the quantification method analysis, and description of the complications observed.Regarding the studies in which complications were observed, they were classified as minor and major . In addiThe initial search generated 921 articles. Based on this review, 24 articles were rated as high quality, 2 as medium quality, and 0 as low quality. Six studies obtained a maximum score of 9 stars .All animals used were adults and skeletally mature. The average age by species is 18 months in dogs and 13 months in sheep. The most commonly used breed was Mongrel in dogs, New Zealand in rabbits, Gottingen in minipigs, and Papio Anubis in non-human primates. The average weight was 17.3 kg in dogs (ranging from 9 to 40 kg), 4.1 kg in rabbits (ranging from 4.15 to 0.55 kg), and 45 in sheep.The 26 articles selected involved 241 patients with 327 distractors; 158 patients had been treated with an extraosseous and 83 with an intraosseous device .Indication and location for distraction. In 23 studies (217 patients), the jaw was used for distraction and in 3 the maxilla (24 patients). The most common location for distraction was the posterior region of the left jaw in all species (82 patients), followed by the posterior region of the right jaw (59 patients); 220 patients had unilateral and 21 bilateral oral distraction .‑8 intraosseous devices: 3i , DL-system , AW , DK KXSLD , STATA 4.0 , OMS , ABDUL , and DID .‑5 extraosseous devices: KLS Martin , OPD , KLS Martin , TRACK 1.0 mm-System , and Impladent SL . Device details. Thirteen different types of commercial distraction devices and other prototypes were found:The most commonly used distractor device was OPD, which was employed in 2 studies and treated 72 patients ,34. The The total number of movable segments were 278. One or more devices may have been placed per segment.VAOD protocol. A latency period of 7 days was by most of the studies, with a mean of 6.13, ranging from 0  to 8 dayVertical bone gain. The main gain achieved in these studies was 6.13 mm (ranging from 2.72 to 8.96 mm). The average gain for extraosseous distractors was 6.26 mm and 6.02 in the case of intraosseous distractors. The study with the highest gain was that of Xie et al. , who recQuantification methods. The quantification methods used whereas follows: histomorphometry (21 studies), X-rays (17 studies), microtomography (5 studies), immunohistochemistry (1 study), and fluorescence microscopy (1 study).Complications and treatment. Complications were found in 12 studies, whereas 11 studies claimed to have had no complications; 3 of them did not supply information.Out of 241 patients, 24 (9.95%) exhibited complications; 11 of them  were major and 13  minor complications. By order of frequency, the minor complications were infection , edema , dehiscence , and alveolar arterial hemorrhage . Using the same criteria, the major complications were: device removal due to a moderate infection , support plate deviation , intra-surgical death , mandibular fracture , and severe diarrhea and death .In 3.31% of the total patients, the distractor was affected due to moderate infection and death of animals, which had to be removed from the study.This review focused on a total of 26 studies that evaluated VAOD. So far, there is no consensus about which is the ideal animal for vertical alveolar distraction tests. In this review, the most commonly used animal, with the least complications, was the dog . Among the breeds, Mongrel was the most used (11 out of 20 studies).Bone regeneration in OD has been related to the age of the patient; faster in young patients, and slower in older ones. In a study performed in rats aged between 4 and 24 months, statistically significant differences were observed in the radiodensity of distracted segment of tibiae; 95% of mineralized bone was observed in 4 month-old rats, whereas in 24 month-old rats, up to 36% of mineralized bone was observed . All theAlthough the procedure of VAOD has been used for over 25 years, there is still controversy over the ideal VAOD protocol. However, the clinical phases of the process  have remained the same. Most of the studies in this review used a latency phase of 7 days, with a mean of 6.13 (ranging from 0 to 8) days, with similar results. Altug et al.  comparedThe period between the initial and the final activation of the distractor is called distraction period. There are multiple options for rate and distraction frequency. Most authors agree on a maximum of 1 mm per day. In this review, the rate oscillated between 0.25 and 1 mm, with a mean of 0.8 mm per day. There are no previous reviews of studies on animals. In humans, a rate ranging between 0.375 and 1 mm  per day Regarding the frequency of distraction, this delicate phase needs to be performed by specially trained staff. In this study, the ranges varied mostly from one to two times per day. In one study, distraction was used once every two days . When diOsteogenic distraction is a technique with the capacity of producing an increase in the height of the alveolar bone that may vary between 4 and 15 mm, with a mean of 9.9 mm . The meaIn the consolidation period, an average of 9.93 weeks was observed (ranging between 0 and 50 weeks). Many discrepancies were found in comparison with studies in humans, with a mean of 12.05 , and 11.Multiple ways to classify complications were studied. In this review, we used a modification of the classification carried out by Enislidis et al.  and SaulThe maintenance of an appropriate level of oral hygiene in animals is sometimes a great challenge. Therefore, surgical sites in the mouth of animals are more likely to get infected, thus increasing the failure rate. Management of pigs and minipigs may be especially difficult, due to the chewing habits, affecting the failure rateAccording to other studies, the most common minor complication is dehiscence ,38. It iThe animal model used in VAOD studies has a marked influence on the results. Within the limitations of the present study, the animal model mostly used and recommendable in VAOD, which shows the least complication was the Mongrel dog. Given the difficulties in handling along with the complications encountered, the use of the pig and minipig as a model for VAOD is not recommended. The possibility to achieve an adequate level of oral hygiene and to reduce the rate and rhythm of activation should be further considered when selecting a suitable animal model for VAOD.


Correlations between maturity (APHV) and MEF for males were from  and for females . Percentiles were calculated for chronological age and APHV. Conclusion: Differences occurred in MEF when compared with other geographical regions of the world. We determined that maturity may be a more effective indicator for analyzing MEF. Reference values were generated using chronological age and maturity.(1) Background: Spirometry is useful for diagnosing and monitoring many respiratory diseases. The objectives were: (a) compare maximum expiratory flow (MEF) values with those from international studies, (b) determine if MEF should be evaluated by chronological age and/or maturity, (c) develop reference norms for children, and adolescents. (2) Methods: A cross-sectional study was designed with 3900 subjects ages 6.0 and 17.9 years old. Weight, standing height, sitting height, and MEF were measured. Length of the lower limbs, body mass index (BMI), and age of peak height velocity growth (APHV) were calculated. (3) Results: Values for the curves (p50) for females of all ages from Spain and Italy were higher (92 to 382 (L/min)) than those for females from Arequipa (Peru). Curve values for males from Spain and Italy were greater [70 to 125 (L/min)] than the males studied. MEF values were similar to those of Chilean students ages 6 to 11. However, from 12 to 17 years old, values were lower in males (25 to 55 (L/min)) and in females (23.5 to 90 (L/min)). Correlations between chronological age and MEF in males were from (r = 0.68, R Pulmonary function may be evaluated by using a variety of simple tests, such as spirometry and maximum expiratory flow (MEF). In addition, more complex and costly tests, such as gas dilution, nitrogen wash, and whole-body plethysmography, may be utilized . In factIn general, the spirometric values are influenced by genetic, ethnic, and environmental factors. These include nutritional state, altitude of residence, smoking, air pollution, nutrition, socio-economic status, and pulmonary illnesses , among oSpirometry is useful for diagnosing and monitoring many respiratory diseases. Furthermore, it also has other potential uses, such as estimating the risk of pulmonary cancer, cognitive deterioration, death due to other causes, or death due to cardiovascular diseases . In addiAs a result, during the past few years, researchers from various international studies have been interested in developing references for MEF for children and adolescents ,7,8. MorIn fact, inhabitants living at high altitudes are exposed to chronic hypobaric hypoxia where the respiratory system plays a critical role in a series of physiological responses. These allow individuals to adapt and tolerate low levels of oxygen in the tissues at high altitudes . In this sense, the proposed MEF references for children and adolescents living at sea level , may notA cross-sectional study was designed with children and adolescents ages 6.0 to 17.9 years old living at a moderate altitude in Peru. The sample size was determined probabilistically (stratified). The sample universe was composed of 28,150 students  from elementary and secondary schools. Students were selected from 6 public schools in the urban area of Arequipa. The final sample was represented by 13.9% (3909 subjects) ; 2045 females (7.3%)). The number of students selected was proportional to the population based on age range and sex (IC 95%).Peru is a country with multiple geographic and cultural differences . For example, the District of Arequipa is comprised of regions with low, moderate, and high altitudes. This study was carried out in the province of Arequipa located at 2320 meters above sea level. During the year, the climate is dry with little precipitation. Temperatures range from 10 °C to 25 °C and with a relative humidity between 46% to 70% . The anthropometric and MEF evaluations were carried out at installations in each school. A team of four experienced professionals was created to conduct and record the evaluations. These were carried out from Monday to Friday during school hours from 8:30 a.m. to 13:00 p.m. Parents and/or guardians authorized their children to participate in the evaluations by signing informed consent. Students also provided signed consent. All students included in the study appeared to be healthy and did not have any illnesses affecting their respiratory system. Parents were asked for the aforementioned information. Students not completing the tests or transferring into the schools from low or high elevations were excluded from the study. All procedures were carried out according to the Declaration of Helsinki for Human Subjects and the recommendations from the Ethics Committee of the Universidad Nacional de San Agustin (UNSA), Arequipa.2.Anthropometric evaluations for weight, standing height, and sitting height were carried out based on the recommendations of Ross and Marfell-Jones  without The maximum expiratory flow (MEF L/min) was based on the protocol proposed by Quanjer et al. . A Mini The age of peak height velocity growth (APHV) was calculated with the anthropometric equation proposed by Mirwald et al. . The staConsidering that the MEF may vary according to age and sex, especially between geographic regions. To compare the MEF references between geographic regions, percentiles proposed by age and sex from Italy , Spain , and Chi2 and standard error of estimation (SEE) were calculated. Percentile curves  were created with the LMS [The Kolmogorov-Smirnov (K-S) test was carried out in order to establish the normality of the distribution of the data by age and sex. Descriptive statistics were calculated of the arithmetic mean, standard deviation, and range. The significant differences between males and females were verified through the t-test for independent samples. The comparisons between the reference studies were graphed (percentile 50). Correlations between variables were carried out by means of the Pearson test. In addition, regression analysis was carried out in steps. The percentage of explanation R the LMS  method.  the LMS  was usedp < 0.05). For sitting height, the values were similar from age 6.0 to 14.0 years old. However, from 15 years old to 17, males showed greater sitting height (p < 0.05). Significant differences occurred only in BMI for males at age 17 where they showed greater BMI. For the state of maturity (APHV), at early ages (6 to 8 years), no differences were found. When compared to males, the females experienced an advanced state of maturation until age 17 years old (p < 0.05).The anthropometric values, APHV (state of maturation), and MEF by age and sex are illustrated in The comparisons between the curves of international studies are displayed in 2 = 0.39), and for females, it was from . Correlations for males for the state of maturity (APHV) and MEF were from , and for females, they were from . In all cases, the significant values were (p < 0.05).The MEF values are arranged by chronological age (years) and maturation (APHV) in p < 0.05) occurred from 12 until 17 years old. When the values were arranged by age of maturation, the results reflected significant differences from 04APHV to 3APHV (p < 0.05).The findings of this research demonstrate that children and adolescents at moderate altitudes in Peru presented lower values of MEF compared to the studies carried out with Caucasian children from Italy  and SpaiThe results of this study are corroborated with research carried out with African American , JapanesIn general, lung function measurements, unlike many other medical observations, are frequently related to body size and age. Here, height is an indicator of chest size and, and age is an indicator of maturity . In the present study, altitude played a key role in the mechanical properties of the respiratory muscles, as the students in this research presented lower body size than their low altitude counterparts in Spain, Italy, and Chile ,7,8. FurTherefore, it was expected that the children and adolescents from Arequipa would present some delay in physical growth. As a result, this could reflect smaller MEF values than those of their peers from Spain, Italy, and Chile ,7,8. ThuAs a result, despite what has been previously described, it cannot be set aside that other factors, such as exposure to environmental contamination, type of occupational activity, and socio-economic status may influence the inter-individual variation in MEF in diverse populations of the world . Thus, fWith regard to the analysis of MEF by chronological age and biological maturity, this research demonstrated that when compared by chronological age, the differences became apparent commencing at 12 years old and onwards. 2 for maturity explained 4 to 6% more than chronological age. This showed that the use of the APHV could be considered as an alternative criterion and acceptable for analyzing the MEF of children and adolescents at a moderate altitude in Peru. However, when arranged by state of maturity, differences were present from infancy to adolescence. Furthermore, RIn some studies, the state of maturation has been reported as the relevant control in samples of children and adolescents . This isIn this sense, childhood and adolescence represent an accelerated growth period of lung capacity and forced respiratory flows  where thFrom this perspective, based on the previous results, for this study, percentiles were created. These were used to evaluate MEF based on chronological age and state of maturation (APHV) for children and adolescents living at moderate altitudes in Peru.These reference values may be useful for evaluating and following respiratory , diseaseIn fact, it is widely known that muscle training improves exercise tolerance, muscle strength, dyspnea, fatigue, and quality of life for individuals . These tThe cut-off points adopted for the proposed percentiles were based on a previous study , where >The references proposed here based on chronological age may overestimate and underestimate the MEF values. However, when controlling for maturity status (APHV) the MEF values reflected better results in relation to chronological age.Some limitations of this study need to be pointed out. Due to the nature of the cross-sectional sample, it is not possible to verify the changes during childhood and adolescence. Therefore, the results should be interpreted with caution. Thus, future research projects need to be designed as longitudinal studies. Furthermore, during this research, it was not possible to control for some of the variables, such as students’ physical activity levels and the absence of a control group of students living at sea level. Thus, such information would have assisted in providing a better interpretation of the results obtained in this study. In addition, it is necessary to emphasize that based on the sample selection and size, and the rigorous protocols followed, the results obtained from this research may be generalized to other contexts with similar characteristics to those of the students from this study. http://reidebihu.net/flujoaqp.php (accessed on 31 January 2021).In conclusion, the results from this study demonstrated that children and adolescents living at a moderate altitude in Peru presented lower MEF values than their peers from other geographic regions of the world. In addition, the results confirmed that maturity (APHV) may be a better non-invasive indicator for analyzing MEF in relation to chronological age. These inter-individual and geographic variations allow the development of reference values for estimating MEF based on maturation and including by chronological age for both sexes. These results suggest the use and application in physical education programs in educational settings and in public health contexts for diagnosing and monitoring respiratory state in pediatric populations at moderate altitudes. The online calculations for this research may be accessed using the following link:


The popularity of electric bicycles in China makes them a common transportation mode for people to commute and move around. However, with the increase in traffic volumes for both vehicles and electric bicycles, urban traffic safety and congestion problems are rising due to traffic conflicts between these two modes. To regulate travel behavior, it is essential to analyze the mode choice and route choice behaviors of travelers. This study proposes a combined modal split and multiclass traffic user equilibrium model formulated as a complementarity problem (CP) to simultaneously characterize the mode choice behavior and route choice behavior of both vehicle and electric bicycle users. This model captures the impacts of route travel time and out-of-pocket cost on travelers’ route choice behaviors. Further, modified Bureau of Public Roads (BPR) functions are developed to model the travel times of links with and without physical separation between vehicle lanes and bicycle lanes. This study also analyzes the conditions for uniqueness of the equilibrium solution. A Newton method is developed to solve the proposed model. Numerical examples with different scales are used to validate the proposed model. The results show that electric bicycles are more favored by travelers during times of high network congestion. In addition, total system travel time can be reduced significantly through physical separation of vehicle lanes from electric bicycle lanes to minimize their mutual interference. In recent years, electric bicycles (E-bikes) quickly became one of the main nonmotorized travel modes in some developing countries, especially in China ,2,3. E-bHowever, with the increase in traffic volumes for both vehicles and electric bicycles, due to traffic conflicts between these two modes, various urban traffic problems are rising, such as traffic safety, traffic congestion, and parking problems. Recently, extensive research efforts were devoted to address the multiple research needs related to E-bikes, such as estimating cycling capacity, the bicycle equivalent unit for E-bikes, consumption behavior of E-bikes users, and characteristics of traffic accident involving E-bikes ,6,7. ExiSimilar to the Braess paradox , overallHence, to simultaneously estimate the mode choice and route choice behaviors of vehicles (cars/automobiles) and E-bikes, this paper proposes a combined modal split and route choice model, with the underlying assumption that all users own vehicles and E-bikes and can choose traffic modes based on the congestion level of each mode. Thus, the general flow pattern is estimated using an user equilibrium model which assumes that nobody can reduce their own travel cost by unilaterally shifting their route or mode at the equilibrium state. Considering the well-established complementarity theory, the proposed multimode traffic assignment model is developed as a complementarity problem (CP).In reality, vehicle lanes and bicycle lanes on some links are separated by physical barriers, while some links have no physical separations. Link cost functions are different under these two cases. In the literature, the Bureau of Public Roads (BPR) cost function  was freq(1)The proposal of a complementarity problem to model the multimode and traffic assignment problems regarding both vehicles and E-bikes, with the uniqueness of solution to this problem analytically discussed;(2)The development of modified BPR functions to capture interactions between the two traffic modes and impacts of characteristics of each mode on link travel time;(3)The consideration of out-of-pocket costs related to factors  affecting users’ mode choice behaviors.In summary, the contributions of this paper include:The rest of the paper is organized as follows. Related literature is reviewed in the next section. In Traffic assignment models are important tools in the design of effective management strategies and operational decisions to improve network performance, for example, they are usually leveraged to deploy infrastructures optimally to reduce traffic congestion ,11,12,13Given Origin–Destination (OD) flows, the user equilibrium problem is treated traditionally as two different methods, namely, deterministic user equilibrium  and stocIn reality, various modes can be chosen by travelers, such as vehicle, public transportation , bike , and so on. To estimate the use ratio of each mode, various methods are proposed, such as discrete choice models ,19. AfteIn the literature, several multimode and/or multiclass traffic assignment models ,21 and cIn existing multimode traffic assignment models, the demand of each mode is normally determined (or assumed to be elastic). That is, these models do not consider mode choice behaviors of users. To address this problem, we first need to study factors affecting mode choice behaviors. This paper focuses on studying the travel behaviors considering users of vehicles and E-bikes. In fact, except for travel time, users choose to use vehicles or E-bikes based on factors such as security, weather, distance, fuel and electricity prices, and so on. Similar to Liu and Li , we defiIn addition, modes such as buses and taxis use the same lanes as vehicles, and modes such as metros do not interfere with vehicles in space at all. Different from these modes, E-bikes are designed to run in bicycle lanes separated from vehicle lanes. On some links, bicycle lanes and vehicle lanes are physically separated, such as by parterres and barriers. However, bicycle lanes and vehicle lanes are separated only by traffic markings instead of physically on some links. In this case, vehicles and E-bikes may occupy each other’s lanes. This interference should be considered in the traffic equilibrium problem, and the existing link travel time function cannot capture this interference.To address the aforementioned gap in the existing research, this paper proposes a combined modal split and route choice model, in which out-of-pocket costs are considered in the mode route cost function and modified BPR functions are adopted to analyze the link travel time of vehicles and E-bikes for links with and without physical separation between vehicle lanes and bicycle lanes.Consider a strongly connected network , where N is the set of nodes and A is the set of directed links. Notations are first given as the following:Travel time on link Flow of vehicles and E-bikes on link Capacity of link Travel time on route Flow of vehicles and E-bikes on route Demand between OD pair , and 0 otherwise;Link–route incidence indicator, which is 1 if link , and 0 otherwise; Route–OD pair incidence indicator, which is 1 if route The route–OD pair incidence matrix with the dimensions Length of link Length of route Minimum (equilibrium) travel cost between OD pair Out-of-pocket costs  of route Costs (including travel time and out-of-pocket costs) of route Suppose route cost functions Equations (1) and (2) are the complementary slackness conditions. That is, for each OD pair To reduce the MCP formulated by Equations (1)–(3) to a pure CP, Equation (3) is reformulated as follows  and (4) is given in Then the CP can be formulated in vector form as follows:Note that if both n method ,34,35,36 methods ,38,39. ISpecifically, route cost functions The route travel time is formulated asOut-of-pocket cost relate to fuel or electricity consumption, vehicle or E-bike depreciation, insurance, security, the environment, and so on. Similar to Liu and Li , we assuAccording to Equations (6)–(8), route costs Note that the linear or nonlinear characteristics of route cost function depend on the function of link travel time –(13) are nonlinear and the proposed traffic assignment model is an NCP. According to the theory of VI/CP , since tThe corresponding Jacobian matrix Theorem 1.According to Equation (10) and Equation (11), the solution to the proposed NCP is unique in cases of physical separation.Proof. For cases of physical separation between vehicle lanes and bicycle lanes, Next, we discuss the case of no physical separation between vehicle lanes and bicycle lanes on links of the transportation network. Theorem 2.Given link time Functions (12) and (13), if> 0, the solution to the proposed NCP is unique for cases without physical separation.Proof. For cases of no physical separation between vehicle lanes and bicycle lanes, according to Equation (14), the first-order leading principal minor of Thus, In Equation (16), Thus, if In summary, if Note that values of Several algorithms were proposed in the literature to solve the traffic assignment problem formulated as an NCP. Among these algorithms, the nonsmooth and semismooth Newton methods were widely used, the basic idea being to convert the complementarity problem into an equal system of equations so as to solve them using the general Newton method.First, we give the following definition.Definition 1.A function According to Definition 1, the NCP function related to NCP (5) can be defined asThen, the solution to NCP (5) can be obtained by solving Note that the NCP function significantly impacts the effective solution algorithm. The following Fischer–Burmeister (FB) function  is frequThe FB Function (20) has many interesting properties, however, it is too flat in the positive orthant (the main region of interest for a complementarity problem) when dealing with a monotone complementarity problem. Chen et al.  introducBased on the NCP Function (21), the equal system of equation related to NCP Function (5) is defined asFurther, we defineThen, a natural merit function The NCP Function (21) and the merit Function (24) were proven by Chen et al.  and Xu eThus, the Newton method introduced by Du Luca et al.  to solveAlgorithm 1. Global algorithm.Step 1.1. Initialize parameters Step 1.2. Initialize solution vector Step 1.3. If Step 1.4. Choose Step 1.5. Linear search. Find the smallest nonnegative integer Step 1.6. Set Step 1.2 is for the initialization of the solution vector Algorithm 2. Initialize the solution vector.Step 2.1. Read in a predefined route set Step 2.2. Load demand Step 2.3. Update the link time and route cost Step 2.4. Load demand Step 2.5. Update the route cost Step 2.6. Select the initial min-route cost Step 2.7. Set the initial solution vector Further, in Step 1.4 of the global algorithm (Algorithm 1), we first need to choose k)T T  choice behavior.First, we apply the proposed NCP to a simple network as shown in The proposed model is further tested using the well-known Nguyen–Dupuis network shown in As discussed before, cases of physical separation are special cases of those without physical separation, with the proposed model only tested for cases of no physical separation between vehicle lanes and bicycle lanes for any link in the network. To check the correctness of the solutions when applying the proposed NCP model to a larger network, To consider the mode choice behavior between vehicles and E-bikes, this paper presented a multimode traffic assignment model formulated as a CP. In this model, the route cost was assumed to consist of route travel time and out-of-pocket cost. Then, the BPR link travel time function was extended for cases with and without physical separation between vehicle lanes and bicycle lanes, respectively. Given the modified link travel time functions, the proposed multimode traffic assignment model became an NCP. Further, the uniqueness of the equilibrium solution to the proposed NCP was proven and a solution algorithm based on the Newton method was developed.Numerical examples were conducted on two different size networks, with the results showing that the solution to the proposed NCP was correct, that is, the solution satisfied the Wardrop UE principle and flow conservation law. Sensitivity analysis showed that since E-bikes are more flexible than vehicles, especially in congested areas, E-bike choice proportion increased with total travel demand and vehicle choice proportion decreased accordingly. Increased in out-of-pocket costs led to a reduction of the corresponding mode choice.Through the comparison of cases with and without physical separations, it was found that reducing the inference between vehicles and E-bikes could significantly reduce total system travel time, indicating that traffic engineers and planners should try to physically separate the flow of vehicles and E-bikes as much as possible.In reality, due to factors such as resource constraints, it is impossible for all links to be physically separated between vehicle lanes and bicycle lanes. Hence, in future research, it would be worthwhile to optimize which links should set up physical separations and extend the proposed CP model to the network design problem. Meanwhile, the application of the proposed model should be tested on real networks, and the modified link travel time function should be verified and calibrated by real link travel data. In addition, some travelers are accustomed to certain traffic modes and do not consider other modes in reality, and some travelers may have more alternatives besides vehicles and E-bikes, such as public transportation. Hence, extending the proposed CP model to consider more types of travelers in the future would be worthwhile.


Heart failure (HF) is the terminal stage of various common cardiovascular diseases with quite a frequent readmission and a high mortality rate, and brings heavy financial burdens to families and society. Oral Chinese patent medicine (CPM) has been widely applied in the treatment of HF in China because of its simplicity, cheapness, convenience, and high efficiency. However, due to the large number and broad clinical selectivity of oral CPMs, there is a lack of uniformity and clinical application standardization. To choose more effective and safe medicine among so many oral CPMs is particularly essential for further improving the therapeutic effect. In this study, the efficacy and safety of different oral CPMs will be compared by a network meta-analysis (NMA), and the best CPM will be selected for the treatment of HF.According to the search strategy, 4 English and 4 Chinese databases will be searched from the construction of the library to July 31, 2020. The NMA will include clinical randomized controlled trials (RCTs) of different oral CPMs in HF treatment. The methodological quality is assessed according to the bias risk assessment tool of Cochrane. The Bayesian NMA is performed by Aggregate Data Drug Information System (ADDIS), and the results are visualized using Stata 15.0 software. The GRADE approach is used to assess the quality of evidence and recommendation intensity.The NMA will identify the best oral CPM in the complementary treatment of HF. A peer-reviewed journal will publish the results of the study.This study can provide reliable evidence for the efficacy and safety of oral CPMs in the treatment of HF, and help decision-makers and patients to select more effective and safer oral CPM.INPLASY202090053. The prevention, treatment, and management of HF is a global public health problem.Heart failure (HF) is an end-stage of various heart diseases with high readmission and mortality rates, which brings heavy financial burdens to families and society. Although significant improvement has been achieved in concept and approaches of HF treatment, the readmission rate is still as high as 25% to 30% after being discharged 30 to 90 days,–7 As previous studies confirmed, combination with TCM based on standardized western medicine treatment can improve symptoms, and reduce readmission and mortality rates of HF patients. Compared with Chinese herbal decoctions and injections, oral CPMs show advantages in carrying, cooking, odor, and using. Therefore, it is more suitable to take for a long time and improve HF patients’ compliance. More than 20 kinds of oral CPMs are applied in the HF treatment; to choose suitable and safe oral PCM is vital for improving treatment effects.Traditional Chinese medicine (TCM) is an effective medicine with a history of 2000 years and widely used in the clinic. It shows apparent advantages in treating HF due to its holistic treatment, multitarget effects, personalized treatment by syndrome differentiation, enhancing physical condition, and reducing side effects of drugs.,10 This study will collect the RCTs of oral CPMs for HF treatment and determine the best oral CPM by screening, analyzing, ranking, and further provide reliable evidence for the clinical application of oral CPMs.At present, there are no direct comparative studies of several oral CPMs in the HF treatment, and it is unrealistic to conduct new clinical trials. With direct and indirect comparisons, a systematic review and network meta-analysis can choose the best treatment plan from numerous interventions.22.1 The protocol has been registered on the INPLASY website, and the registration number is INPLASY202090053 (URL https://inplasy.com/inplasy-2020-9-0053/). The ethical approval and patient informed consent are abandoned because this study is based on published or registered RCTs.This NMA is guided by the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015.2.2Eligibility criteria under the guidance of the PICOS principle include the following.2.2.1 the 2014 “Expert Consensus on TCM Diagnosis and Treatment of Chronic Heart Failure.” Patients who have received coronary artery bypass surgery or cardiac resynchronization therapy, or accompanied by noncardiovascular events such as malignant tumors, mental illnesses, or severe liver and kidney dysfunction are excluded. No restrictions are imposed on nationality, age, gender, and race.Patients diagnosed with HF according to any of the diagnostic criteria are eligible to be included, such as the 2014 “Guidelines for the Diagnosis and Treatment of Heart Failure in China,”2.2.2The treatment group is defined as treating with oral CPMs based on western medicine, and the control group is defined as treating with western therapy alone or placebo or blank. According to the guidelines and expert consensus, oral CPMs mainly include Qili Qiangxin Capsules, Shexiang Baoxin Pills, Shengmai Capsules, Shenfu Qiangxin Pills, Tongxinluo Capsules, Xinbao Pills, Xuefu Zhuyu Capsules, Danshen Dripping Pills, Xinkeshu Pills, Zhenyuan Capsules, Qishen Yiqi Dripping Pills, etc. Western medicine mainly includes Ace inhibitors/Angiotensin II receptor antagonists, β-receptor blockers, aldosterone receptor antagonists, diuretics, nitrates, antiplatelet drugs, anti-myocardial ischemia drugs, and statins, etc.2.2.3The primary efficacy outcomes contain mortality, other cardiovascular events; the secondary efficacy outcomes contain New York Heart Association classification (NYHA classification), left ventricular ejection fraction (LVEF), quality of life (QOL) scores, brain natriuretic peptide (BNP)/N-terminal pro-brain natriuretic peptide (NT-proBNP), 6-minute walk test (6-MWT), the safety indicators contain adverse events such as itchy skin or rash, nausea, vomiting, dizziness, dry cough, etc.2.2.4All published or ongoing RCTs of oral PCMs for HF will be included. Research sources mainly include journal papers, conference papers, and graduation thesis. The self-control and review literature, case report, experience summary, and repeatedly published literature is excluded.2.32.3.1According to the search strategy, 4 English databases include PubMed/MEDLINE, Web of Science, EMBASE, Cochrane Library, and 4 Chinese databases include China National Knowledge Infrastructure (CNKI), Wanfang Data, Chinese Scientific Journal Database, Chinses Biomedical Literature Database (CBM), which will be searched. The search time is from the establishment of the database to July 31, 2020. We will also search for ongoing RCTs, such as trials registered and conducted on WHO International Clinical Trial Registration Platform. The languages are restricted to Chinese and English.2.3.2In addition to a comprehensive search of the databases, manual search, tracking of references, and retrieving through search engines are also carried out.2.4The search terms include HF, Chinese patent medicine, Chinese herbal medicine, randomized controlled trial, and their synonyms. The strategy based on the combination of free-text terms and Medical Subject Heading (MeSH) is used for searching, and each database adopts a different search strategy according to its characteristics. Two members will develop and implement the search strategy independently, and a third member will further amend it. The detailed search strategy of PubMed is summarized in Table 2.5The Endnote software  is used to classify and organize and delete repeated literature. We will read the title and abstract to preliminarily screen and eliminate the literature that does not meet the requirements, and further read the full text to screen literature. Two members will perform literature screening independently, and if there are differences in opinion, they will discuss and resolve in consultation with the third member. The results of the literature screening will eventually be presented in the form of a flow chart. Two members are required to extract data independently with data extraction table, and then the data are input into statistical software after checking. The data extraction contents are as follows.2.5.1The basic features of RCT include title, first author, year of publication, country, journal.2.5.2Participants characteristics include age, sex, inclusion/exclusion criteria, sample size, baseline characteristics.2.5.3Type of CPMs, treatment time, research design, randomization, distribution concealment and blindness.2.5.4Primary efficacy outcomes, secondary efficacy outcomes, safety indicators.2.5.5Study design and quality (using bias risk assessment tools).2.6 For divergent literature evaluation results, independent evaluation and adjudication will be conducted by a third member.The methodological quality evaluation is one of the most important parts of the NMA, and it is the judgment of the authenticity of the research. The quality evaluation is mainly carried out by evaluating the bias risk in the design and implementation of clinical trials. All included literature is evaluated by the bias risk assessment tool of the Cochrane Handbook Version 5.2.0 for Systematic Reviews of Interventions, and 7 items are included in the tool. All biases are evaluated in 3 risk levels: low, uncertain, and high.2.72.7.1,17 After the statistical analysis, the convergence needs to be measured by the potential scale reduction factors (PSRE). The closer the PSRE is to 1, the better the convergence. PSRE greater than 1.1 or 1.2 means the number of simulations needs to be increased to achieve good convergence. After the consistency model analysis is completed, the rank probability and relative effects are used to compare the effects of CPMs.In this study, the Stata software  is used for pairwise meta-analysis. The odds ratio (OR) and mean difference (MD) is used as the effect sizes of continuous and categorical variables, respectively. The 95% confidence interval (95% CI) is calculated to represent the possibility of the results in this interval. The Aggregate Data Drug Information System (ADDIS) (Version for Windows 1.16.8) is used for NMA, and Markov-chain-Monte-Carlo (MCMC) is used to perform Bayesian inference. Perform iterative operations based on preset model parameters.2.7.2P value are used to analyze statistical heterogeneity among the research results qualitatively, with P ≤ .05 indicating that there is statistical heterogeneity. I2 is used to analyze statistical heterogeneity quantitatively, with I2 > 50% indicating substantial heterogeneity. According to the heterogeneity assessment result, the fixed-effect model or random-effect model is selected to estimate the synthesized effect size.Before implementing the analysis, the clinical and methodological heterogeneity should be analyzed and identified. Only when the clinical and methodological features are similar enough can the effect size be synthesized. The heterogeneity is assessed for each pairing comparison using Stata 15.0 software. Chi-square test and 2.7.3 It is necessary to analyze the causes if there is heterogeneity in the research results. Subgroup analysis will be carried out according to research characteristics related to the heterogeneity source. For example, if the heterogeneity may be caused by the methodology's quality, the hierarchical analysis may be carried out according to methodology quality; if different design schemes may cause it, the hierarchical analysis will be carried out according to the design scheme.In the process of effect size synthesizing, only when the included studies have the least heterogeneity, the credibility of the synthesized effect size is high. Sensitivity and subgroup analyses are the most common approaches to solve heterogeneity. Stata 15.0 software is used to analyze the sensitivity if the results of NMA are positive, and more than 3 studies are included. The sensitivity analysis is carried out by excluding study one by one. If no significant change exists in the results before and after the exclusion, it indicates that the sensitivity is low and the results are of stability and reliability; otherwise, it means a high sensitivity, and unstable results.2.7.4P value. The P > .05 indicates that the results of the direct comparison are consistent with indirect comparison, and there is no statistical inconsistency.When there are closed loops in the NMA, the inconsistency is needed to assess. The Node-Split Model can calculate the differences between direct and indirect comparisons of evidence, and judge whether there is inconsistency according to the size of the 2.7.5A funnel plot is used to assess the potential publication bias if the NMA includes 10 or more studies. The rank correlation test proposed by Begg or the linear regression method proposed by Egger is used to test the symmetry of the funnel plot. The X-axis of the funnel plot represents the effect size of each study, and the Y-axis represents the effect size's standard error. Taking the synthesized effect size as the central axis and making a vertical line on the X-axis. The point on the left side of the vertical line represents the effect size of the study is less than the synthesized effect size, and the point on the right represents the effect size is greater than the synthesized effect size. If the points on both sides are the same, it means the publication bias does not exist; otherwise, there is publication bias.2.8 The quality of evidence refers to the degree to which people can determine the predicted value's correctness, and can be categorized into high, medium, low, and very low. Recommendation intensity refers to the extent to which you can be confident that compliance with recommendations outweighs disadvantages, and can be divided into 2 levels: strength and weakness. The basic application principle of GRADE approach in NMA mainly includes 5 downgrade factors.The GRADE approach is used for evaluating the quality and recommendation intensity of evidence.3,21 TCM is an effective supplement and substitute for primary and secondary prevention of cardiovascular diseases. It can improve HF patients’ cardiac function and life quality as adjuvant therapy. Among all kinds of TCM, oral PCMs have been widely applied in HF treatment due to its portability, convenience, low cost, and high efficiency in China. Previous systematic reviews and meta analyses on Qili Qiangxin capsules, Qishen Yiqi dripping pills, Shexiang Baoxin pills, Wenxin granules, and other oral PCMs show good efficacy and safety in the treatment of HF.,23–25With the continuous updating of evidence-based therapies in recent years, Ace inhibitors/Angiotensin II receptor antagonists, β-receptor blockers, and aldosterone receptor antagonists have become common drugs for HF, which can effectively improve clinical symptoms and patients’ life quality. However, the prognosis of HF patients is still unfavorable. Exploring effective treatment methods, improving HF patients’ prognosis is a public health issue of global concern.Most previous studies focus on the clinical efficacy comparison of one oral PCM and western medicine in the treatment of HF. There is still a lack of a comparison of clinical efficacy and safety of several PCMs. There are many kinds of oral PCMs in the clinic, which shows a better effect in the treatment of HF is still unknown. In this study, an NMA is conducted by comparing primary efficacy outcomes, secondary efficacy outcomes, safety indicators of all RCTs of oral PCMs in the treatment of HF, and the probability is further ranked according to the indicators. This NMA aims to select the best clinical medicine for the treatment of HF with oral PCMs.This study has several disadvantages: First, we have taken various measures to improve the searching quality as much as possible. However, due to the impossibility of searching all databases and insufficient search of unpublished studies, there may still be incomprehensive literature. Second, the published RCTs of oral PCMs in the treatment of HF lack strict randomized design, and with low quality, this may reduce the credibility of the study. Third, only English and Chinese literature is included in this study, which may lead to selection bias. Anyway, this study can provide a reliable result for the best medicine selection and strong evidence for the significant advantages of oral PCMs in the treatment of HF.Conceptualization: Hui Guan, Hua-hua Dai.Data curation: Hui Guan, Wulin Gao, Ning Wang, Lili Ren, Zhenhao CaiFormal analysis: Hui Guan, Ning Wang, Lili Ren, Zhenhao Cai.Funding acquisition: Hua-hua Dai.Methodology: Hui Guan, Wulin Gao.Project administration: Hua-hua Dai.Writing – original draft: Hui Guan, Ning Wang.Writing – review & editing: Hui Guan, Hua-hua Dai, Guohua Dai.


The future of awake bruxism assessment will incorporate physiological data, possibly electromyography (EMG) of the temporal muscles. But up to now, temporal muscle contraction patterns in awake bruxism have not been characterized to demonstrate clinical utility. The present study aimed to perform surface EMG evaluations of people assessed for awake bruxism to identify possible different subtypes. A 2-year active search for people with awake bruxism in three regions of the country resulted in a total of 303 participants . Their inclusion was confirmed through non-instrumental approaches for awake bruxism: self-reported questionnaire and clinical exam, performed by three experienced and calibrated dentists (Kappa = 0.75). Also, 77 age- and sex-matched healthy controls were recruited . Temporalis surface EMG was performed with a portable device . EMG signals were sent to a computer via Bluetooth 4.0 at a sampling rate of 1,000 Hz. Digital signal processing was performed using the commercial neuroUP software, transformed in RMS and then normalized for peak detection (EMG peaks/min), in a 10 min session. Cluster analysis revealed three distinct subtypes of awake bruxism: phasic, tonic, and intermediate. Individuals with a predominance of EMG peaks/min were classified as the “phasic” subtype (16.8%). Those with the highest EMG rest power were classified as the “tonic” subtype (32.3%). There was also an “intermediate” subtype (50.8%), when both variables remained low. Characterization of awake bruxism physiology is important for future establishment of instrumental assessment protocols and treatment strategies. Bruxism is an umbrella term for different motor phenomena/behaviors of the masticatory muscles. An international consensus defined awake bruxism as a masticatory muscle activity behavior during wakefulness that is characterized by repetitive or sustained tooth contact and/or by bracing or thrusting of the mandible , and is influenced by psychological factors, such as stress and anxiety, a quite common situation in the post COVID-19 pandemy . A control group consisted of 77 healthy, age-matched volunteers  who were evaluated by the same specialists. All volunteers signed a statement of informed consent in compliance with Resolution n° 466/12 of the National Board of Health, and this study received approval from the human research ethics committee of the Center of Health Sciences of the Federal University of Pernambuco (process 65515417.1.0000.5208).An observational, analytic, and cross-sectional study was conducted. The participants were recruited by convenience from private healthcare services over 2 years (2017–2019) in the northeastern, central-western, and southeastern regions of Brazil. An active search was conducted in all centers to recruit subjects with a high probability of awake bruxism. The clinical signs of awake bruxism were disclosed. Possible candidates to the research study came spontaneously or were recruited by clinicians for an evaluation by a specialist. Only those volunteers compatible with the international consensus : presence of self-reported jaw movements with or without associated pain symptoms, and (2) orofacial clinical signs identified by a dentist. The study exclusion criteria were: history of head trauma, presence of degenerative neurological diseases, stroke, open lesions in the region of the anterior temporal muscle, severe visual or hearing impairment, previous botulinum toxin injection in the masticatory muscles , or having undergone other concomitant rehabilitation treatments in the previous month.linea alba on the inner cheek, damage to the dental hard tissues, failures of restorative work/prosthodontic constructions, or mechanical wear of the teeth. The Tooth Wear Evaluation System (TWES), recommended by Wetselaar and Lobbezoo (n = 30 in each group). The three dentists examined the same patients. The data were analyzed, reviewed, and discussed; discrepancies in the data were re-examined. Finally, a reliability session was conducted, and the kappa index was calculated. The calibration procedure continued until a kappa index of 0.75 was reached, indicating an excellent agreement among the three dentists . EMG signals were sent to a computer via Bluetooth 4.0 at a sampling rate of 1,000 Hz. Digital signal processing was performed using commercial software , with a 60-Hz Notch filter to avoid electrical artifacts and a Butterworth bandpass filter (30–500 Hz) to reduce low frequencies artifacts  and to guarantee a reading of up to half of the sampling rate (Nyquist Theorem). The signals were transformed in real-time to calculate the root mean square (RMS). Before the evaluation, an automatic measurement of the signal quality was performed in the software. EMG data were also processed by an algorithm that automatically calculates the amount of electric field gradients per minute. The counting of peaks per minute was based on individualized normalization, not on absolute values. Sudden increases in EMG signal above 80% of the patient's own basal was identified as a peak. This cutoff value was defined in a pilot project carried out prior to the research and was the most accurate value in the identification of phasic contractions.Standard disposable surface adhesive electrodes with Ag/AgCl sintered composition were used. These electrodes were placed with a distance of 20 mm between them . In addiThe EMG procedure lasted ~10 min. Pilot studies from our group (data not shown) and also studies from other laboratories have shown that this period suffices for an EMG evaluation  for pain was used to measure pain intensity. The VAS used was unidimensional, and the volunteer marked the intensity of pain, from zero (no pain) to ten (intense pain). This scale was applied before palpation to avoid trigger points being activated, and participants were instructed to respond about the current painful perception felt at the time of the assessment.p < 0.05), and 95% confidence intervals were calculated.As the objective of present work was to search for profiles of EMG markers in volunteers with awake bruxism, it was decided to perform a cluster analysis. Cluster analysis is a statistical method for organizing data into relatively homogeneous groups that differ from each other according to the variables of interest. All data were plotted in a 2D chart with phase contractions  against their rest EMG power (uV RMS). These data were inserted in the automatic cluster analysis of SPSS software, using hierarchical cluster analysis  are necessary.Future studies will be able to identify whether different psychomotor profiles and different brain circuits can influence the prevalence of phasic and tonic contractions in people with awake bruxism. In addition, understanding the different EMG patterns may assist in choosing specific treatments in cases where bruxism causes harmful consequences. According to Wetselaar et al. , bruxismThe international consensus in bruxism states that assessment of this condition may be performed by non-instrumental and instrumental approaches, such as physiological parameters acquired by EMG , with no significant differences in VAS scores between them.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Comitê de ética em pesquisa com seres humanos—CEP UFPE. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.UM and VS: term, conceptualization, methodology, formal analysis, investigation, data curation, writing - original draft, writing - review and editing, and project administration. CS and TP: validation, investigation, and writing - review and editing. RX: term, conceptualization, methodology, validation, resources, writing- original draft, and writing - review and editing. MA: conceptualization, methodology, resources, writing - review and editing, and funding acquisition.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Older adults with multiple chronic conditions (MCC), and especially with added depression, have lower levels of daily activity than those without MCC. Engagement in daily activities can be measured by ability  and performance . Understanding this difference is critical to developing interventions that align with the daily activity needs of older adults with MCC. The aim of this study was to understand the relationships between ability and performance of instrumental activities of daily living (IADL) among older adults with varied MCC and depression status. We conducted a cross-sectional study using data from the National Health and Aging Trends Study. We used MANOVA to detect differences in ability and performance of IADL by MCC status and t-tests to test the difference between ability and performance for our sample. There was an effect of MCC status on ability and performance for older adults in this sample, F  = 67.12, p < .001, ηp2 = .05; performance and ability were lowest for MM-D, and highest for no MCC. Post-hoc t-tests revealed a difference between the mean scores for ability  and performance  across all groups of MCC status, t (6693) = -50.174, p < .001. Older adults with MCC, particularly with depression, displayed diminished performance of IADL, although they have the ability. Our results suggest interventions should not only address what individuals can do, but also what they actually do in their context.