Jewish MCL participants reported lower depressive symptoms (p < 0.001) than non-participants, however no difference was found between Arab MCL participants and non-participants (p < 0.160). Amateur team sports such as MCL are related with higher levels of well-being and social capital. Future research should focus on longitudinal studies that examine the change in social capital and well-being over time.The Israeli Mamanet Cachibol League (MCL) serves as a community model that incorporates physical activity and amateur team sports among women. Team sports have been shown to bridge gaps and build positive relationships between communities. There is a paucity of data regarding the advantages of team sports to promote the health and well-being of women from different ethnic backgrounds. The purpose of this study was to examine the association of participation in MCL with social capital, health, and well-being across two ethnic groups: Jewish and Arab women. A cross-sectional survey was conducted among women aged 25–64: 102 Jewish and 96 Arab MCL participants, and 102 Jewish and 81 Arab non-MCL participants. Data regarding social capital  and well-being  were analyzed using two-way analyses of covariance and multiple regression models with sequential entry of the variables. MCL participants from both ethnic groups reported higher social capital ( In recent years, a considerable body of literature on social capital has emerged linking social capital to a number of positive outcomes, including health indicators and well-being ,2. SociaWell-being describes a wide range of ways in which people experience and express their lives in either a positive or a non-negative manner. There are those who equate well-being with bliss and joy, others view well-being as a state of sustained contentment, and for others it is simply a state of good physical and mental health. All of these views are correct but none of them stands alone, meaning that well-being cannot be fully represented by any one measure .There are two major conceptual approaches to well-being . In the The second approach consists of several concepts, which have been referred to as eudaimonic well-being (EWB). This approach assumes there are a number of needs or qualities essential for one’s psychological growth and development. Fulfillment of these needs enables individuals to reach their full potential . AnotherAmong women, social capital has been found to be associated with well-being: higher levels of happiness, life satisfaction ,11, qualSocial capital may explain some of the health disparities that exist among social groups, such as self-rated health, psychological health, and psychological distress . High soThe development of social capital is especially important in poor, deprived, or segregated communities because of the lack of resources and social networks within the community . In IsraIn addition, health indicators in Israel present a picture of poorer health in the Arab population compared to the Jewish population . AlthougOne health risk factor that may add to the disparities in health between Jews and Arabs could be PA, where disparities have been reported between Jewish and Arab women. According to the Israeli Ministry of Health, Arab women report a lower rate of regular leisure PA (42%) compared to Jewish women (59%). In addition, only 24% of Arab women reported exercising for at least 30 consecutive minutes three times a week or more compared to 33% among Jewish women .There are many barriers for conducting PA among women, including time and resource limitations and necessary childcare ,29. For Team sports include activities that require teamwork, socialization, and commitment to PA, all of which are associated with social capital . ParticiParticipation in team sports can also contribute to better physical and mental health . It reduTeam sports have previously been used as a method for creating positive associations between communities and bridging differences between cultures and ethnicities . As womeEven though there is evidence that team sports may increase social capital, which in turn contributes to an active and healthy lifestyle, there is a paucity of data regarding the advantages of team sports on the health and well-being of women from diverse backgrounds. Baron-Epel et al.  found inCachibol  is a team ball game that has characteristics similar to volleyball. The game was invented in 1895 by Clara Gregory Baer, a physical education pioneer at Sophie Newcomb College in Louisiana, USA . In bothhttps://www.mamanet.org.il/International.asp).The Mamanet Cachibol League (MCL) was established in 2005 as a community model that incorporates PA, sports education, social networks, and support, among women from different population groups. In Israel, MCL currently encompasses thousands of players in over 90 Arab and Jewish municipalities throughout the country. The MCL teams have a weekly practice and they compete against each other in local and national tournaments. Participants in MCL attend local and national community events, including activities that involve spouses and children of the participants. MCL is also active internationally in various countries including Canada, Cyprus, Finland, Germany, Greece, Italy, Singapore, and the United States , among both Arab women and Jewish women.To assess whether social capital was associated with well-being  among both Jewish and Arab women.The purposes of the present study were:We performed a quantitative cross-sectional study among a sample of 381 MCL participants from the Arab and Jewish sectors: 198 MCL participants (102 Jews and 96 Arabs) and 183 non-participants . An online questionnaire was delivered to participants and included information about health indicators , psychological characteristics (psychosomatic and depressive symptoms), and social capital . Arab and Jewish women who did not participate in MCL but had similar sociodemographic characteristics to the MCL participants were used as a comparison group.The sample of Jewish participants was recruited with the help of the MCL organization, which provided names and phone numbers of the teams’ captains, to whom the online questionnaire was sent. The captains sent out the online questionnaire via the WhatsApp application (text message) to all of their team’s members.The sample of Arab participants was also recruited with the help of the MCL organization, but unlike the Jewish MCL participants, the Arab participants filled out a “pen and paper” questionnaire delivered by a research assistant. The reason the Arab participants filled out a printed version of the questionnaire was due to the fact that many did not own smart phones and were therefore unable to access the questionnaire online via their cell phone. Previous research has suggested only minor differences between online and paper questionnaires ,44,45.The sampling method was stratified sampling. MCL management provided the list of active teams that have been active for at least one year across Israel. A total of 10 teams were sampled from the Jewish sector, which included 102 participants. Ten teams from the Arab sector were sampled, which included 96 participants. Teams from different geographic regions and socio-economic levels  according to the Israeli Central Bureau of Statistics  were incThe questionnaire was built for the study purposes and was based on valid questionnaires from the scientific literature ,48,49,50Self-reported health (SRH) : Self-rePsychosomatic symptoms : PsychosDepressive symptoms : The scaParticipation in MCL was measured by participation or non-participation (yes/no).Demographic characteristics: Demographic characteristics included age, number of children, family status (married/in a relationship), education level , and family income .Body mass index: BMI was calculated according to participants’ reports about weight and height and was used as a control variable for self-reported health.Social capital : Social The first component, social trust, was comprised of 3 items including: “In general, do you think that most people can be trusted, or that you can’t be too careful in dealing with people?” and “In your opinion, would most people try to take advantage of you if given a chance, or would they try to be fair to you?” Eigenvalue was 3.67, explaining 30.59% of the variance. Loadings ranged between 0.77 and 0.85, and internal consistency was α = 0.82.The second component, social support, was comprised of 5 items including: “’How many close friends do you have?” and “To what extent do you feel appreciated by society?” Eigenvalue was 1.79, explaining 14.89% of the variance. Loadings ranged between 0.54 and 0.72, and internal consistency was α = 0.69.p < 0.001), and thus a total score for social capital was composed as well (α = 0.78).The third component, social involvement, was comprised of 4 items including: “To what extent have you participated in any community event in the past six months?” and “To what extent are you likely to meet friends or acquaintances when you go out shopping in your area of residence?” Eigenvalue was 1.19, explaining 9.89% of the variance. Loadings ranged between 0.47 and 0.76, and internal consistency was α = 0.60. The generally agreed upon lower limit for Cronbach’s alpha is 0.70. However, in exploratory research it may decrease to 0.60 . ConfirmBackground characteristics were described by group and ethnicity, with frequencies and percent, means and standard deviations, and compared with Z tests and analyses of variance. Skewed variables were log or exponentially transformed. The mean scores of the main study variables are presented (Table 2); the associations between them were examined using the Pearson correlation (Table 2). Analyses of covariance were calculated for the study variables, by group and ethnicity, controlling for age, education level, and BMI (Table 3). Significant interactions between group and ethnicity were interpreted with estimated marginal means. Multiple regressions with sequential entry of the variables were calculated for SRH, psychosomatic symptoms, and depressive symptoms (Table 4). The first step included group , ethnicity , age, and education level ; BMI was included regarding SRH only. Step 2 included the dimensions of social capital. All data were analyzed in SPSS version 26  .The sample included a total of 381 participants: 198 MCL participants (102 Jews and 96 Arabs) and 183 women in the comparison group , and significant and negative for psychosomatic and depressive symptoms . They were positive for academic education with social capital , and negative for depressive symptoms . Family income was highly correlated with education level (r = 0.46 p < 0.001). Lastly, BMI was negatively associated with SRH (r = −0.14 p = 0.008). Thus, the study hypotheses were examined while controlling for age and education level . Analyses regarding SRH were controlled for BMI as well. Analyses of covariance were calculated to assess differences in the study variables by group and ethnicity, controlling for age and education level.Correlations between the study variables and the women’s ages were significant and positive for social capital . However, there was no significant difference between MCL and the comparison group among the Arab participants  = 1.98; p = 0.160; η2 = 0.005).A significant interaction between group and ethnicity was found in depressive symptoms. Among the Jewish participants, the MCL group had lower depressive symptoms compared to the comparison group  = 26.52; Multiple linear regressions with sequential entry of the variables were calculated to assess the extent to which MCL participation, ethnicity, the background variables, and social capital were associated with SRH, psychosomatic symptoms, and depressive symptoms, as shown in Results revealed that all regression models were significant. The explained variance ranged between 8% (SRH) to 32% (depressive symptoms). Group was significant for all three regressions. That is, SRH was higher for MCL participants than non-participants, and psychosomatic and depressive symptoms were lower. Ethnicity was significant for SRH and depressive symptoms. That is, both SRH and depressive symptoms were higher for Arab women than Jewish women.Beyond the background variables, better SRH was associated with lower BMI and higher social support. Experiencing fewer psychosomatic and depressive symptoms was associated with higher trust and social support, beyond group and ethnicity. Lower depressive symptoms were further associated with higher social involvement.Our findings suggest that Jewish women (including MCL participants) have higher levels of social capital  compared to Arab women (including MCL participants). These differences in social capital between the two ethnic groups are consistent with previous literature that point to the effects of socioeconomic and cultural differences, such as lower education and income levels and higher poverty, crime and violence levels among the Arab population in Israel ,23,24. IConcurrently, the findings also suggest that both Jewish and Arabs participants in MCL had higher levels of social capital  and well-being  compared to each of the comparison groups. Previous literature suggests that social connections, social interactions, and social networks involving amateur team sports contribute to the development of social capital among participants ,29,55,56Findings related to higher levels of social capital among MCL participants relative to the comparison groups may also be related to MCL participants being more inclined to participate in social activities compared to non-participants. In a pre-post study design of Jewish women, Baron-Epel et.al found that social support and social involvement were higher to begin with among women who participated in an MCL program when compared to women who did not, therefore it is reasonable that these findings are similar . AccordiThe disparities in well-being between MCL participants and non-participants may suggest that that MCL participants feel physically and mentally better than non-participants. Previous studies have suggested a positive connection between participation in PA and health status ,58,59. PAn interaction between group (MCL/non-MCL participants) and ethnicity (Arab/Jewish women) showed that Jewish participants in MCL had lower depressive symptoms compared to the comparison group, but there was no such significant difference among Arab participants in MCL compared to the comparison group. The Israeli National Health Interview Survey 2003–2004, found that the rate of depression among Arab women was 1.7 times higher than that of Jewish women . Kaplan A number of factors may be related to the lack of improvement in depressive symptoms despite participation in MCL. Various cultural and social factors have been found to be related to mental health and well-being of Arab women, including community values , rigid hThese sociocultural norms and values can be significant barriers to Arab women’s participation in sports and PA. Specifically, several studies point to impediments that limit participation in sports and PA for Arab women in Qatar ,69, MalaAnother purpose of this study was to assess the associations between social capital and well-being among Jewish and Arab participants in MCL. Our findings suggest that associations exist between social capital and well-being, beyond ethnicity and group. These findings are consistent with previous literature suggesting that social connections are a leading source of human well-being ,73. MoreSeveral limitations of the study should be noted. Firstly, there is an issue with causality regarding social capital and well-being, as the cross-sectional design of the study involved no possibility to distinguish the directions of cause and effect. Women who participated in MCL might have tended to be more socially oriented than non-participants. Secondly, the distribution of MCL in the Arab society in Israel is relatively low. Less than 5% of MCL participants are Arab, when Arabs are nearly 21% of the general Israeli population. The sample of the Arab MCL participants was in fact a small convenience sample, chosen from a small number of teams. Finally, this was not an intervention study with a random assignment of women to comparison and intervention groups. Therefore, it would be logical to claim that the women who participated in MCL may have been more socially inclined to join, and possibly had higher levels of social capital to begin with.In conclusion, our findings suggest that amateur team sports such as MCL are related with higher levels of well-being and social capital, in particular social involvement. Future research should focus on longitudinal studies that examine the change in social capital and well-being over time, particularly among Arab participants.


Primary insomnia (PI) is a common disease affecting human health. As the side effects of drug therapy were revealed, people began to seek more safe and effective non-drug therapies. Cognitive behavioral therapy for insomnia (CBT-I) and acupuncture are 2 commonly used non-drug therapies. However, there are few comparative studies on the efficacy of these 2 therapies. Therefore, this study aims to compare the efficacy and safety of the 2 therapies through network meta-analysis.We will search the following electronic bibliographic databases: PubMed, EMBASE, The Cochrane Library, Web of Science, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, Chongqing VIP database, and Wanfang database. Randomized controlled trials in which the intervention was acupuncture or CBT, and in which the control group was any of the above, western medicine or blank control, would be included. The primary outcome will be the changes of the Pittsburgh Sleep Quality Index, and the additional outcomes will include the changes in Insomnia Severity Index, quality of life, clinical effective rate and adverse events. Two independent authors will screen the literature in the above database, extract data and cross-check. Heterogeneity and inconsistencies are detected before using a network meta-analysis method based on frequency analysis. The risk of bias will be assessed in accordance with the Cochrane risk of bias tool, and the strength of the recommendations will be assessed by the Grading of Recommendations Assessment, Development and Evaluation.This network meta-analysis will provide a reference for clinicians and PI patients to choose a more appropriate non-drug regimen among multiple kinds of acupuncture or CBT-I therapies. This review does not require ethical approval and will be reported in a peer-reviewed journal.PROSPERO CRD42020155327 It is reported that there are about a fifth of the world's population has suffered from insomnia,–5 and the incidence rate is increasing year by year.–7 Recent research has found that insomnia could increase the risk of cardiovascular and cerebrovascular diseases, psychiatric diseases, and diabetes.–11 Insomnia, therefore, has become a worldwide health problem that cannot be ignored.Primary insomnia (PI) is a common health disease characterized by difficulty in initiating or maintaining sleep, which is associated with daytime consequences, and lack of clear cause. However, these drugs are not perfect and still have some side effects. For example, a study from the United States found that frequent adverse events associated with drug therapy included inefficacy, drug resistance, amnesia, and nightmares, with inefficacy being the most common complaint. Therefore, non-drug therapy has been paid more and more attention in clinical practice. Cognitive behavioral therapy for insomnia (CBT-I) is currently preferred non-drug therapy without side effects. A systematic review found that CBT-I was effective in treating PI and preventing its recurrence.Pharmacotherapy is the most commonly used treatment for PI because of convenience and effectiveness.–17 Acupuncture is a physical stimulation therapy that originated in China and widely used in the Asian. Acupuncture has been added to the guidelines for the diagnosis and treatment of insomnia in China. As far as we know, acupuncture is also a popular alternative medicine in the United States. Insomnia is among the top 10 acupuncture indications in the United States, according to an investigation of private clinics in 2018. Recent network systematic reviews have shown that several kinds of acupuncture methods were all effective and safe in improving the condition of patients with PI compared with drugs.Although Many guidelines have recommended CBT-I as a first-line treatment for PI, most acupuncture studies rarely use it as a control group, often choosing either a positive drug or a placebo as a control group. There are only a handful of randomized controlled trials (RCTs) that directly compare acupuncture with CBT-I in the treatment of PI. For these reasons, there is no systematic review of direct comparisons between acupuncture and CBT-I.In recent years, growing evidence demonstrated that acupuncture was also a safe and effective nonpharmacological treatment in improving sleep quality and cognitive function. In recent years, NMA has already been used successfully to compare different acupuncture methods for treating insomnia disorder, but few have focused on comparing it to CBT-I. Therefore, this systematic review and NMA based on high-quality RCTs data aims to analyze the comparison between different acupuncture therapies and CBT therapies and their safety and to calculate the effect size. Secondly, by ranking these non-drug regimens, we hope that the results of this study will provide a reference for clinicians and patients to choose the best non-drug treatment.Which non-drug treatment is the best choice for patients with PI between CBT-I and acupuncture? The answer is unclear, for lack of sufficient evidence. To solve the question, we will use a network meta-analysis (NMA) method that provides the possibility of comparing the indirect evidence. NMA can compare multiple interventions simultaneously and combine direct and indirect evidence to select the best treatment.22.1 and registered at PROSPERO (CRD42020155327). The final report will under the guidance of the PRISMA Extension Statement for Reporting of Systematic Reviews Incorporating Network Meta-Analyses of health care interventions and the Cochrane Collaboration Handbook for systematic reviews of interventions (V.5.1.0).This systematic review and NMA will assess the comparative effectiveness and safety of acupuncture treatments and CBT-I treatments for PI. This protocol is drafted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols2.2Since our research is based on published research findings that have been reviewed by the Ethics Committee, this study does not require ethical approval.2.32.3.1All the RCTs of acupuncture and CBT-I in treating PI regardless of blinding and concealment will be included. However, only literatures written in English or Chinese will be included.2.3.2Participants diagnosed with PI by either of the following diagnostic criteria will be included: diagnostic and statistical manual of mental disorders, international classification of sleep disorders, Chinese classification and diagnosis of mental diseases, as well as other accepted diagnostic criteria without gender, age, and ethnic origin restrictions.2.3.3Intervention: The experimental groups will be treated with acupuncture , and CBT-I .Comparator: The control groups include drug treatment group and blank group. Or either of the described intervention compared with each other is also eligible.2.3.4The primary outcome will be the changes of the Pittsburgh Sleep Quality Index.; quality of life obtained from the corresponding scale; clinical effective rate and adverse events,The additional outcomes will include the following items: sleep score measured by Insomnia Severity Index2.3.5Studies that do not have data available or cannot be extracted will be excluded.2.4We will search the following electronic bibliographic databases: English databases  and Chinese databases  from their inception to October 1, 2019. We will also search for ongoing trial registers in the trial registry websites. At the same time, we will retrieve other potential articles manually in the reference list of retrieved studies to ensure the comprehensiveness of this research. There will be no restrictions on date limit, country, publication status, or year of publication.We will use a combination of medical subject heading or keywords, and free-text terms with various synonyms. The medical subject heading or keywords used for the search will contain “acupuncture”, “insomnia”, “CBT-I”, “RCT” and synonymous words. The preliminary retrieval strategy for PubMed is presented in Table 2.5Two reviewers (JW and QHH) will independently screen the literature in the above database, extract data, and cross-check. The retrieved articles will be imported into the Endnote software (version X9.2). They will screen these articles based on inclusion and exclusion criteria. The flow chart is displayed in Figure The contents we want to extract are as follows:(1)general information: include authors, journal, publication year, country, methods of randomization, and blinding;(2)participants: include age, sex, duration of insomnia symptom;(3)interventions and controls: include the type of therapy, the course of treatment, dosage forms, and clinical doses;(4)outcomes: include the primary and secondary outcomes, measurement time points, and the proportion of adverse events.2.6 The following characteristics will be assessed: random sequence generation, allocation concealment, blinding of participants, and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other bias. Any disagreements will be resolved by discussion or discussed with another researcher (YT or QHH) if necessary.Two researchers (YZ and WP) will evaluate the risk of bias independently according to the Cochrane Collaboration's risk of bias tool.2.72.7.1http://www.r-project.org/). We will use the “netmeta” package in R to complete the network meta-analysis. This package overcomes the difficulties of the software and package developed based on Bayesian statistical school in realizing the network meta-analysis. We will perform network meta-analysis combining direct and indirect comparisons from the included RCTs.Data analysis will be performed with the R software 3.6.1 (For the direct comparisons, if there are more 2 RCTs, we will conduct a pairwise meta-analysis. For the results of indirect comparison, a network meta-analysis will be needed to adjust and mix results to improve accuracy and statistical efficacy. Continuous variable data will be presented as the standard mean difference with 95% confidence interval, whereas dichotomous data will be presented as odds ratio with 95% confidence interval. For direct and indirect comparisons, we will present the results through a network diagram.2.7.22 statistic. If the value of I2 is less than or equal to 50%, the heterogeneity is small, and the fixed effect model will be used to combine the effect size. Conversely, if I2 > 50%, the source of heterogeneity was further analyzed. After excluding the influence of apparent clinical heterogeneity, the random effect model was used for meta-analysis.Before choosing fixed or random effect model to combine the effect size, we will run a heterogeneity test. The purpose of heterogeneity test is to check whether the results of individual studies are mergeable, and the test will be performed by calculating I2.7.3If the heterogeneity is higher than 50%, we will conduct subgroup analysis and sensitivity analysis to explain the sources of heterogeneity. The subgroup analyses will be based on age, interventions, controls, and population area, while the sensitivity analyses based on research features or types.2.7.4Z test when a loop is established among interventions.Consistency hypothesis is an important hypothesis in network meta-analysis. It can assess the difference between direct comparative evidence and indirect comparative evidence. Inconsistency will be assessed by 2.7.5 If the distribution of the points on both sides of the vertical line in the funnel plot is uniform, it means that there is no publication bias, and on the contrary, there is publication bias.We will also use funnel plots and Egger test to identify whether there is a small sample effect evaluation or potential publication bias.2.8 The quality of evidence in Grading of Recommendations Assessment, Development and Evaluation is classified as high, medium, low, and very low. Factors that reduce the quality of evidence include risk of bias, indirectness, inconsistency, imprecision, and publication bias. In addition, there are 3 factors that promote the level of evidence: large effect size, dose-effect relationship, and related confounding.The evidence quality will be evaluated by the Grading of Recommendations Assessment, Development and Evaluation.3,32–33 Previous studies have found that auricular acupuncture had a greater effect on sleep duration in insomniacs than CBT.–35 However, due to the small number of studies, the traditional systematic evaluation cannot reach a reliable conclusion. Whether acupuncture is better than CBT-I remains to be further studied. Treatments that are safe, effective, and have fewer side effects are more acceptable to patients. CBT-I and acupuncture have both been shown to be safe and effective non-drug therapies.,36 Which is the best choice for patients? The network meta-analysis is beneficial in the absence of direct evidence. It provides an indirect comparison between the 2 treatments using a common control group. It can also rank a variety of acupuncture therapies with CBT, and help clinicians to choose a suitable non-drug therapy for insomnia patients.We designed this network meta-analysis protocol on the basis of previous studies.Conceptualization: Wei Peng, Ying Zhao, Tianmin Zhu.Data curation: Jun Wang, Qinghong Hao.Formal analysis: Wei Peng, Ying Zhao.Funding acquisition: Tianmin Zhu.Investigation: Wei Peng, Ying Zhao, Jun Wang, Qinghong Hao, Yang Tu.Methodology: Wei Peng, Yang Wang.Supervision: Tianmin Zhu.Writing – original draft: Wei Peng.Writing – review & editing: Ying Zhao, Yang Wang, Tianmin Zhu.


To explore the predictive performance of machine learning on the recurrence of patients with gastric cancer after the operation. The available data is divided into two parts. In particular, the first part is used as a training set , and the second part is used as a test set (the remaining 20% of the data). And we use fivefold cross-validation. The weight of recurrence factors shows the top four factors are BMI, Operation time, WGT and age in order. In training group:among the 5 machine learning models, the accuracy of gbm was 0.891, followed by gbm algorithm was 0.876; The AUC values of the five machine learning algorithms are from high to low as forest (0.962), gbm (0.922), GradientBoosting (0.898), DecisionTree (0.790) and Logistic (0.748). And the precision of the forest is the highest 0.957, followed by the GradientBoosting algorithm (0.878). At the same time, in the test group is as follows: the highest accuracy of Logistic was 0.801, followed by forest algorithm and gbm; the AUC values of the five algorithms are forest (0.795), GradientBoosting (0.774), DecisionTree (0.773), Logistic (0.771) and gbm (0.771), from high to low. Among the five machine learning algorithms, the highest precision rate of Logistic is 1.000, followed by the gbm (0.487). Machine learning can predict the recurrence of gastric cancer patients after an operation. Besides, the first four factors affecting postoperative recurrence of gastric cancer were BMI, Operation time, WGT and age. It has been reported that the average time to recurrence of gastric cancer was 20.5–28.0 months after operation2. However, when gastric cancer recurs after the operation, some chemotherapy and immunotherapy can be used in close cooperation to control cancer and reduce necrosis, to create conditions and strive for operation.The global incidence of gastric cancer is the fourth in malignant tumors and the second in mortality. There are nearly 1 million cases of new gastric cancer worldwide each year, of which nearly 50.0% occur in China. The prognosis of early gastric cancer is good, but the clinical symptoms are atypical and the signs are not obvious. The postoperative recurrence rate (40.0–70.0%) remained high3. Using machine learning technique can predict the malignant degree of breast lesions4; Machine learning was used to better predict early biochemical recurrence5; Machine learning is a branch of artificial intelligence, which has been used in tumor risk assessment, lesion detection, prognosis prediction and treatment response6; Deep learning can effectively solve medical problems that were previously thought unsolvable7.In recent years, big data and machine learning have led to innovative changes in many industries. With the development of precision medicine plan, the combination of health and medical big data and machine learning brings people the imagination space of the future big data health cause. The method of machine learning is especially suitable for prediction based on existing data. By capturing complex nonlinear relations in the data, the machine learning algorithm can improve the accuracy of prediction more than the conventional regression model. At present, machine learning can predict the survival of breast cancer patients at an early stageIn conclusion, postoperative recurrence of gastric cancer are key factors affecting the prognosis of gastric cancer, and it is very important to actively explore the adverse factors affecting postoperative recurrence of gastric cancer to detect and evaluate the recurrence or metastasis of postoperative gastric cancer. Therefore, we used a machine learning technique to predict the tumor recurrence of gastric cancer patients after operation.Data is available at BioStudies database, accession numbers: S-EPMC4344235. This study included 2012 patients.Data from the retrospective studies included age, gender, pathological characteristics, treatment-related factors, and the follow-up period related to survival status.Logistic regression, a kind of generalized linear regression analysis model, is often used in such fields as automatic disease diagnosis and economic prediction.The decision tree algorithm belongs to the category of supervisory learning.In machine learning, a random forest is a kind of classification/regression which contains multiple decision trees (CART tree). The final classification result is decided by each decision tree vote/ average, that is, a few obey the principle of most. The stochastic forest in turn corresponds to the fusion of the model of several decision trees (CART trees).The GBDT is also called MART. It is an iterative decision tree algorithm. The trees in GDBT are all regression trees. Only the accumulation of the results of regression trees is meaningful, and the addition of the results of classification is not meaningful.The light GBM (light gradient boosting machine) is a framework to implement GBDT algorithm, which supports efficient parallel training.10. Then the trained model is applied to the test set for prediction. Choose the best model according to its performance on the test set11. And the data are normalized by us. The parameters of the machine learning model are shown in Supplementary Table Data were processed in R (3.5.3) language. P < 0.05 was taken as the difference with statistical significance; Multiple imputations were used for missing variables. The machine learning was analyzed by python (3.6.5). The total population was randomly divided into a training group and test group according to the ratio of 8:2. The available data is divided into two parts . In particular, the first part is used as a training set , and the second part is used as a test set (the remaining 20% of the data). Then, a prediction model is established by using the training set. To get the best model, manual parameter adjustment and grid search are used. And we use fivefold cross validation25.Because this is only a secondary data analysis study using public databases, there is no need to apply for ethicsComparison of basic indicators of patients in the two groups: there was no statistically significant difference in age and height between the two groups (P = 0.697 and P = 0.982). See Table The results of gbm algorithm showed that the first 4 factors were ranked in order: BMI, Operation time, WGT and age, respectively Figs.  and 2.FiIn training group: among the 5 models, the accuracy of gbm was 0.891, followed by gbm algorithm was 0.876; The AUC values of the five algorithms are from high to low as forest 0.962), gbm (0.922), GradientBoosting (0.898), DecisionTree (0.790) and Logistic (0.748). The precision of forest is the highest 0.957, followed by the GradientBoosting algorithm (0.878).The recall rate for forest is up to 0.478, followed by the gbm (0.451) , GradientBoosting 0.774), DecisionTree 0.773), Logistic (0.771) and gbm (0.771), from high to low. The highest precision rate of Logistic is 1.000, followed by the gbm (0.487).The highest recall rate was 0.309 for the DecisionTree, followed by the gbm algorithm (0.235)  makes ROC, AUC-ROC, and especially accuracy, less useful in assessing the utility of a predictor. So we have adopted the AUC chart with the highest precision. And this imbalance in classification is normal in the application of machine learning-related medicine because the incidence and non-incidence of diseases are unbalanced.This study is addressed by the classification task. It should be to use accuracy (Ac), sensitivity (Sn), specificity (Sp) Matthews coefficient correlation (MCC) and AUCAlthough machine learning has yielded good results in predicting the postoperative recurrence of gastric cancer, the present study has some limitations. Some patients were excluded due to lack of data, which may lead to selection bias. Besides, due to retrospective data, our study failed to refine the prediction of recurrence in some subgroups of the postoperative gastric cancer population, such as patients with gastric cancer combined with other malignant tumors and patients with gastric cancer with other special medical histories, which may cause some applicability of the study results. Further prospective studies on this aspect are needed in the future.To sum up, machine learning can predict the recurrence of patients with gastric cancer after an operation. Besides, the first four factors affecting postoperative recurrence of gastric cancer were BMI, Operation time, WGT and age.Supplementary Table S1.


Dual purpose chickens are one solution to the killing of male day-old chickens from the layer strains. However, modern laying hen husbandry faces further challenges, for instance, the frequent occurrence of injurious pecking. This behavior is seen as a sign of stress in the offending birds, it causes pain and damage in the victims, and thus impairs the health and welfare of the whole flock. In this study, the behavior of conventional laying hens and dual-purpose hens was evaluated comparatively by assessing the status of their feathers and skin over time. All hens were housed and managed under semi-commercial conditions. Severe feather loss and skin lesions due to injurious pecking only occurred in the conventional layer flocks. Therefore, keeping dual-purpose hens may also be an alternative approach to overcome damaging behaviors in laying hen husbandry.p < 0.05). Within the LB+ strain, the proportions of hens affected by plumage loss and injuries differed among batches (p < 0.05), whereas this was not the case in the LD flocks. Thus, severe feather pecking and cannibalism seemed to occur in the conventional layer hybrids but not in the dual-purpose hens, though both genetic strains were raised and managed under the same semi-commercial conditions. Therefore, keeping dual-purpose hens should also be considered as an alternative approach to avoid injurious pecking in laying hen husbandry.Dual-purpose strains, with hens housed for egg laying and roosters kept for meat production are one alternative to the killing of male day-old chickens. However, dual-purpose hens seem to have additional advantages compared to conventional layers, for instance, a lower tendency to develop behavioral disorders, such as feather pecking and cannibalism. In the present study, three batches of about 1850 conventional layers  and 1850 dual-purpose hens  each, all of them with untrimmed beaks, were observed during production (20–71 (56) weeks of life) in a semi-commercial aviary system. The aim was to investigate whether the hybrid and batch affected the occurrence of injurious pecking, and to identify a detailed time course of the damage caused by this behavior. Therefore, the hens’ plumage and skin condition were assessed as an indicator by means of a visual scoring method. The LB+ hens had higher production performances and higher mortality rates compared to the LD hens. Plumage loss in the LB+ flocks started at 23 to 25 weeks of age, and deteriorated continuously. The LD hens showed only moderate feather loss on the head/neck region, which started at 34 to 41 weeks and remained almost constant until the end of the observations. Compared to feather loss, injuries occurred in the LB+ hens with a delay of several weeks, with a maximum of 8% to 12% of hens affected. In contrast, skin injuries were observed only sporadically in single LD hens. In all batches, hybrid had an effect on the occurrence of feather loss ( The term “injurious pecking” summarizes several undesirable behaviors of partly different etiology in laying hen husbandry. All of these behaviors have in common that they are directed at conspecifics  in which they cause physical damage to varying extents. Feather pecking refers to the non-aggressive pecking at, plucking of, and often also removing and ingesting of the feathers of the recipient , and is The main welfare issue of injurious pecking is obvious: The occurrence of this behavior in a laying hen flock is indicative of poor or stressful housing and management conditions . FurtherHowever, the propensity to develop injurious pecking is not only influenced by resource-related factors but also by genetic background . In obseThe original idea behind keeping these dual-purpose strains nowadays is to avoid the killing of day-old male layer chickens, which raises socioethical and, in some European countries, also legal concerns . Dual-puIn a previous study, Giersberg et al.  found evThe aim of this longitudinal follow-up study was to investigate whether the hybrid strain consistently affected the occurrence of injurious pecking in an on-farm setting, and to identify a detailed time course of the feather and skin damage caused by this behavior. Based on previous research and observations in practice, it was hypothesized that both feather loss and integument lesions indicating injurious pecking behavior would occur to a larger extent in conventional layer hybrids compared to dual-purpose hens. In addition, it was expected that within the hybrid strain, plumage and integument condition might differ among batches.The present study was carried out at the research farm “Ruthe” of the University of Veterinary Medicine, Hannover, Germany, and involved a total of 5517 Lohmann Brown plus  and 5501 Lohmann Dual hens , all of them with untrimmed beaks. LB+ hens had brown feathering and laid brown eggs, whereas LD hens had white feathering and laid cream-colored eggs. The hens were kept in three consecutive batches, and were observed from November 2015 to September 2018.From one day old to 19 weeks, the LB+ and LD chickens from the first batch were housed in two separate pens, with about 1850 hens each, in the same building at a commercial rearing farm in northern Germany. In the second and the third batch, both hybrids were kept for the first 18 weeks of life in two adjacent pens, again with about 1850 hens each, in the rearing house at the research farm “Ruthe”. At both locations, the pullets were raised according to standard management procedures, which were developed to meet the requirements of the LB+ strain . They ha2) [At 18 or 19 weeks of life, respectively, the hens were moved to the layer house at “Ruthe”, where, again, both hybrids were subjected to the same housing conditions and standard management procedures, which were established for the LB+ hens . The hen2) , which w2) ) followi2) . ProductAs an indicator for injurious pecking behavior, the plumage and integument condition of the hens was assessed by a mere visual scoring method (VSc), which was developed and validated earlier . VSc wap-values were <0.05.All of the statistical analyses were performed using the software SPSS Statistics . Owing to the large overall data set, feather scores were summarized according to the following scheme: Intact plumage (former score 0), moderate plumage loss (former scores 1 and 2), and severe plumage loss (former scores 3 and 4). Since feather loss on the breast/belly region could not be identified reliably by the VSc method , scores The present study complies with the requirements of the ethical guidelines of the International Society of Applied Ethology . All of Basic production data for the end of the respective study period of the three batches of LB+ and LD hens are provided in In this section, the summarized target variables  are plotted as time lines per batch and hybrid. The detailed proportions of LB+ and LD hens with different plumage status on the four distinct body regions are provided in the The time course of moderate feather loss on at least one body region is presented in As stated before, severe plumage loss was not observed in the LD hens. Therefore, the proportions of hens with >50% of the feathers missing on at least one body part are presented for the LB+ flocks only . Severe Injuries indicating cloacal or toe cannibalism were not observed in either of the two hybrid strains. In the LD hens, only one hen with skin lesions was found in batch 3 at 43 weeks of life . Therefop < 0.05), the second (t(490) = 34.11, p < 0.05), and the third batch (t(490) = 49.95, p < 0.05), respectively. In all of the observed flocks, there were more LD than LB+ hens with fully intact feather cover. Within the hybrid, effects of batch were found in the LB+ strain, with more hens with completely intact plumage in the first compared to the second batch (t(490) = 9.27, p < 0.05), in the first compared to the third batch (t(490) = 25.91, p < 0.05), and in the second compared to the third batch (t(490) = 16.71, p < 0.05). No effect of batch was observed within the LD flocks.As expected from the descriptive time lines, the proportion of hens with completely intact plumage  was affected by hybrid in the first (t(490) = 24.84, p < 0.05; batch 2: t(490) = 20.92, p < 0.05; batch 3: t(490) = 19.19, p < 0.05). Pairwise comparisons showed that more LB+ hens were affected in the third compared to the first (t(490) = 9.86, p < 0.05) and the second batch (t(490) = 8.01, p < 0.05), and in the second compared to the first batch (t(490) = 2.37, p < 0.05). In the LD strain, the proportions of hens affected by moderate plumage loss did not differ among batches.Similar results were obtained for the proportions of hens with moderate plumage loss on at least one body region, which were higher in the LB+ than in the LD flocks in all batches (batch 1: t(490) = 19.28, p < 0.05) and 3 (t(165) = 15.11, p < 0.05) compared to batch 1, whereas no difference was detected between batch 2 and 3 (t(165) = 1.27, p = 0.20).As mentioned earlier, severe plumage loss was not observed in the LD, and in the LB+ hens before 36 weeks of life. Therefore, the influence of batch was only tested in the LB+ flocks at a later age. From the 36th week onwards, more LB+ hens with severe plumage loss were found in batch 2 (t(165) = 20.01, p < 0.05) and the third batch (t(165) = 3.50, p < 0.05), and in the third compared to the first batch (t(165) = 3.82, p < 0.05).Injuries indicating cloacal or toe cannibalism were not observed in either of the two hybrid strains. Similar to severe plumage loss, injuries in the LB+ flocks occurred from the 36th week of life onwards. Thus, the following results refer to the LB+ strain at 36 weeks or older. The proportions of injured hens differed among all batches, with more animals affected in the second compared to the first (t(165) = 20.73, The present study provides a longitudinal, comparative record of plumage and integument condition of dual-purpose hens (LD) and conventional layer hybrids (LB+) kept under semi-commercial housing and management conditions. As hypothesized, severe feather loss and skin lesions only occurred in the LB+ hens. Within the hybrid strain, batch influenced the prevalence of damage in the LB+ but not in the LD flocks.Feather loss and injuries, particularly on the bird’s back, rump, and tail, are valid indicators of injurious pecking behavior in laying hens . These cIn all of the observed LB+ flocks, plumage loss started only a few weeks after transfer to the laying hen house and deteriorated rapidly thereafter, so that at 30 to 32 weeks of life, half of the hens of each batch were affected. This is in line with previous investigations under commercial  and expeIn contrast, none of the above described patterns was found in any of the LD flocks. In the LD hens, slight feather loss was observed on the head/neck, starting from 34 to 41 weeks of age. This may be explained by aggressive pecking behavior, which was found to cause feather loss on the head .Correspondingly, hybrid effects were found for the proportions of hens with intact plumage and moderate feather loss in all batches. Due to the absence of severe plumage loss and injuries in the LD hens, it was not possible to test these variables for hybrid effects. Previous research confirmed a genetic background of the development and expression of injurious pecking behavior . TheAs stated before, from the present study one cannot conclude which environmental factors might have triggered the observed feather loss and skin lesions, which indicated the development of injurious pecking in the LB+ flocks. The hens were housed in a semi-commercial setting, which can be regarded as representative for many laying hen farms in Europe. Known risk factors for behavioral disorders were largely eliminated, for instance, by providing permanent access to litter and alfalfa bales as additional standard enrichment material . HoweverThus, the present study confirms the patterns of the preliminary data set used for validating a method for plumage and integument assessment . BesidesThe major challenge of the dual-purpose concept is to keep the animals in an ecologically and economically sustainable way. As expected, the LD hens showed a lower production performance in terms of laying rate and number of eggs laid per average hen housed. However, compared to the LB+ hens, the LD hens consumed about 20% less of a standard layer diet in the present study. Furthermore, the average feed consumption in kg per kg of produced egg mass was similar in both hybrids. In addition, feeding LD hens an energy- and nutrient-reduced diet containing 10% lignocellulose was associated with a decrease of body fat content and an improvement of laying performance . TherefoThe dual-purpose concept must certainly not be regarded as the exclusive approach to prevent injurious pecking effectively and in the short term on commercial farms. Although it might not be applicable for a large share of egg producers to house dual-purpose hens at present, this concept can contribute to a diversification of poultry production towards sustainable, welfare-friendly systems. Other perspectives, such as management approaches, should be further developed and re-evaluated in on-farm contexts . HoweverKeeping dual-purpose hens with untrimmed beaks under standard management procedures in semi-commercial loose housing systems is largely unproblematic regarding the occurrence of damaging behaviors. In three consecutive batches, the dual-purpose hens did not show signs of feather pecking or cannibalism throughout the laying period, whereas the conventional layer hybrids showed an increasing prevalence of feather loss and skin injuries from early to mid lay to late lay. These results indicate that dual-purpose hens may experience higher levels of welfare in aviary systems compared to conventional layer hybrids. Thus, keeping dual-purpose hens should be considered as one alternative approach to avoid injurious pecking in modern laying hen husbandry.


This study was aimed to investigate the relationship between geometric parameters of furcation lesions - maximum area of lesion opening (MALO), angle formed between the roots (ABR), lesion volume (LV) and presence and height of infra-osseous defects (IOD) - and the success of therapy with enamel matrix derivative proteins (EMD) in patients with grade C periodontitis, using cone-beam computed tomography (CBCT).The study consisted of two groups of patients with grade C periodontitis: control (surgery) (n = 17) and test (surgery + EMD) (n = 17). Images parameters on CBCT were recorded using OnDemand3D and ITK-SNAP software.P = 0.01), with a moderate positive correlation (R = 0.59). MALO was found to be statistically significant (P = 0.03) in the test group (surgery + EMD), with moderate negative correlation (R = -0.5).Pearson's correlation coefficient demonstrated that only IOD was statistically significant in the probing depth PD (The presence of infra-osseous defects and height were relevant in relation to the success of the type of treatment addressed in this study. Cone beam computed tomography; Digital volume tomography; Furcation defect; Furcation involvement; Periodontal regeneration; Periodontal disease. The initial intervention consists of oral hygiene instructions and oral environment adequacy. Mechanical procedures are part of the basic intervention in which open flap debridement (OFD) is considered the gold standard for treating periodontal diseases. For treatment of grade C periodontitis, however, single mechanical intervention may not reduce periodontal pathogens in affected sites as the disease may persist .Therefore, several authors have searched for therapeutic alternatives to improve the treatment and prognosis of patients with grade C periodontitis , 2, 3, iAmong the aforementioned regenerative approaches, there is a technique using enamel matrix derivative proteins (EMD), in which amelogenins are the main component. EMD has brought significant improvements in the regenerative treatment of periodontal defects caused by periodontal disease. These proteins have the ability to promote periodontal ligament regeneration, in addition to increasing the formation of mineralized matrix and to releasing growth factors. Studies have shown that EMD can also reduce the local pathogenic flora, thus creating a more favorable environment for periodontal regeneration .Diagnostic imaging is a valuable tool for complementing clinical examinations. Conventional radiographic methods, including periapical and panoramic radiographs, have been frequently used to estimate the degree of furcation lesions. However, these methods are inherently limited as they provide only two-dimensional images, and consequently, overlapping structures and varying degrees of distortion may occur. Three-dimensional images obtained with cone beam computed tomography (CBCT) allow these structures to be reliably evaluated and, therefore, this technique should be considered for the study of periodontal diseases , 7.CBCT is currently considered a reliable imaging technique for diagnosis and treatment of furcation lesions, including infra-osseous defects and other periodontal problems . ResearcAlthough there are studies addressing the importance of CBCT in the diagnosis of furcation lesions, there are a few ones specifically addressing their geometrical parameters.In this context, based on the promising role of EMD in the periodontal regeneration process and on the fact that CBCT is a high-capacity imaging technique for analysing periodontal lesions, in addition to providing different three-dimensional information on the periodontal lesion and involved tooth, this study aimed to investigate the relationship between tomographic parameters of furcation lesions in upper molars and the success of EMD therapy in patients with grade C periodontitis.22.1The sample selection was conducted at the Periodontics Clinic of the São José dos Campos School of Dentistry and Institute of Science and Technology of the São Paulo State University (ICT-UNESP) and the subjects for this study were a subset of a previously research of aggressive periodontitis.The sample consisted of 34 patients diagnosed with grade C periodontitis who met pre-established criteria for inclusion.Grade C periodontitis corresponds to one in which there is a rapid rate of progression, that is, loss greater than or equal to 2.0 mm in more than five years, and destruction exceeding the expectation for biofilm deposits with specific clinical patterns suggestive of periods of rapid progression and/or early-onset disease .This study was approved by the local human research ethics committee according to protocol number #1.734.857 and was conducted in accordance with the Helsinki Declaration of 1975, as revised in 2000. All patients provided written informed consent to participate.I)Aged between 18 and 35 years old.II)Presence of grade C periodontitis  in at leIII)Presence of at least 20 teeth.IV)Good systemic health.V)Signing an informed consent form agreeing to participate in the study, after explanation of the risks and benefits.The inclusion criteria were as follows:I)Presence of systemic problems  contra-indicating the periodontal procedure;II)Previous periodontal treatment in the last 12 months;III)Previous use of antibiotics and anti-inflammatory drugs in the last six months;IV)Being smoker, pregnant or lactating;V)Chronic use of medications affecting the response of periodontal tissues.The Exclusion criteria were as follows:2.2Patients were submitted to further scan by using an I-CAT Next Generation unit  operating at a 0.125-mm voxel size, 40-second image acquisition, 37.07 mA, 120 kVp, voxel size of 0.20 mm, exposure time of 26.9 s and field of view (FOV) of 8.0 × 8.0 mm.The images acquired were converted into DICOM  format for use with OnDemand3D  and ITK-SNAP 1.4.1  software. All images were measured by one calibrated investigator who was trained by a radiologist with experience of 6 years in CBCT images, in addition to being previously calibrated and unaware of the treatment received by the patients. Examiner calibration was conducted as follows: the investigator measured the MALO, ABR, VDL and IOD of ten patients twice within a 24-hour interval. Subsequently, the measurements were submitted to intraclass correlation test and the examiner was considered calibrated as the agreement was above 90%.2.3To determine the MALO, the images were converted into DICOM format for use with OnDemand 3D software. Initially, the occlusal plane of each patient was previously corrected by using the axis-cutting tool on the images so that it was always parallel to the horizontal plane, thus establishing a standardized process.2. To this end, the multiplanar reconstruction mode (MPR) was used in which axial slices are viewed in the occlusal-apical direction, allowing the furcation lesion to be observed in the tooth , providing a value in mmhe tooth A. After 2.4In order to obtain an individual angular measurement between the roots of the three maxillary molars under study, the CBCT DICOM images were exported to the OnDemand3D software. The axial section was selected by using the TMJ tab in the axial window, thus making it possible to visualize the middle thirds of the three roots. Next, by using the Curve tool, a segment line was drawn, two by two, around the roots of the tooth studied. This segment line resulted in a perpendicular cut allowing individualized view of the roots in their full extent. These cuts were scanned to determine which one could allow the best view of the roots. The Angle tool was then used so that the vertex of this angle coincided with the furcation region of the roots and the angle's sides coincided with the long axis of the roots, ending at their apex. Next, the ABR was determined in degrees B. This p2.5LV was obtained by using the ITK-SNAP 3.4.0 software , allowing the axial sections of the images to be visualized, that is, the region(s) of interest of the tooth with furcation lesion. In order to obtain the volume, manual segmentation was conducted by using the Polygon tool, in which the lesion was delimited in the axial sections to generate its individual area. At the end of this process, that is, after all the lesions had their areas segmented in the occlusal-apical direction, the volume of the lesion was calculated based on the segmented areas A.Figure 2.6For this, the images were evaluated by using the OnDemand3D software, more specifically the Dental module. Initially, by means of the Axis-cutting tool, the long axis of the tooth was adjusted so that it remained perpendicular to the horizontal plane.Next, in the axial section, the elements in question were located in the middle thirds of the three roots . With the Arc tool, a semi-straight line was drawn equidistant to the buccal roots (i.e. MB and DB) and perpendicular to an imaginary line joining them. This semi-straight line generated perpendicular buccopalatal cuts automatically, which were displayed in the cross-section window. This enabled to gradually follow the bone levels from the entrance of the furcation between these roots to their central region, which were vertically measured with the Ruler tool from the furcation to the bone level, thus providing values of the matching bones. Next, the same procedure was repeated considering the MB and P roots as well as DP and P roots, two by two, thus determining the presence of infra-osseous defect considering each face of the furcation B.Three heights were progressively measured when bone defect was observed between the roots, that is, in the palatal, intermediate and buccal regions of the furcation, corresponding to the same infra-osseous defects. After the measurements, root defects were averaged for each tooth studied.The tomographic parameters are shown in 2.7This was a prospective, randomized, controlled, clinic triple-blinded study. All patients underwent an initial treatment aimed at adequacy of the oral environment, in which they received information about their periodontal status before being instructed about oral hygiene and undergoing supragingival calculus scraping, prophylaxis and coronary polishing.All patients underwent an initial treatment of grade C periodontitis, which consisted of oral hygiene counseling, prophylaxis, adequacy of the oral environment, supragingival scraping and ultrasound debridement of the whole mouth, as well as information about their periodontal status. Even after periodontal debridement, the patients received oral hygiene instruction so that they could achieve a plaque index <20%. During these sessions, supragingival scraping was also conducted to maintain optimal oral hygiene.I)Test group (OFD + EMD): Periodontal scraping and root planing + EMD application .II)Control group (OFD): Periodontal scraping and root planing.After re-assessment, proximal sites of maxillary molars with grade 2 furcation involvement, probing depth (PD) of 5 mm or greater, vertical and horizontal insertion loss ≥5 mm, and presence of bleeding were distributed according to the quadrant to be treated as follows:Surgical treatment was conducted by a single operator as follows: antisepsis of the facial region was performed with 0.2% chlorhexidine digluconate; sterile eye drops for perioral skin disinfection; and 10 mL of 0.12% chlorhexidine digluconate as mouth-rinse solution  for 1 min for intraoral disinfection. After the preoperative procedures, local anesthesia with 2% mepivacaine and epinephrine at 1:100,000  was injected in the patient by infiltration technique. Next, OFD was performed according the modified Kirkland surgery flap technique . With a 15-cm blade, intrasulcular incisions were made to the bottom pocket in the buccal, lingual and interproximal areas, extending in the mesial and distal directions. The gingival tissue was detached from the underlying bone tissue to expose the root surfaces, which were then scraped and flattened. Visible granulation tissue and calculus were manually removed with the aid of curettes  and ultrasonic device  was used for scraping. Diagnosis of grade II furcation was confirmed by using Nabers probe (Hu-Friedy). At this point there is a treatment randomization.The test group received application of EMD as specified by the manufacturer . After scraping, the site was abundantly irrigated with saline solution. After hemostasis, the root surfaces were kept dry and then EMD gel was applied.All clinical measurements were conducted by a single examiner (NCCS), who was previously calibrated and unaware of the treatment given to the patients. The examiner calibration was done as follows: The examiner measured the PD and clinical insertion level of 15 patients twice within 24 h. Next, the measurements were submitted to intraclass correlation test and the examiner was considered calibrated as a 90% agreement was reached. Evaluations were conducted prior to treatment (baseline) and after six months. The following parameters were evaluated: plate index, gingival index, PD – measured from the bottom of the pocket to the gingival margin by using a North Carolina periodontal probe (UNC-Hu-Friedy), and horizontal clinical insertion level (HCAL) – horizontal distance between clinical insertion into the furcation and the base of the stent, measured by using a modified Nabers probe. All measurements were expressed in millimeters to assess the horizontal component of the defect . Furcation defects were classified according to Hamp et al.  by using2.8Statistical analysis was performed by using independent t-test or Mann-Whitney's test and Chi square test for demographic characteristics of the patients. A combined result was defined as “Delta” (Δ): final values minus initial values for PPD and HCAL. The comparisons between groups were performed by using two-way ANOVA and Pearson's correlation test.All statistical analyses were performed by using the software SAS System for Windows, version 9.4.  at a significance level of 5%.3P > 0.05).Analysis of the demographic data was performed, which is shown in P > 0.05). Additionally, it can be emphasized that there were no significant variations in PPD or HCAL at the baseline and after six months in both test and control groups.Clinical results at the baseline and six months after the treatment are shown in The Pearson's correlation test was used to assess the possible presence of correlations between tomographic parameters  and clinical parameters (reduction of PD and increase of HCAL) in both groups (surgery and surgery + EMD). The results are shown in P = 0.01) in the height of the furcation defect, with a moderately positive correlation (R = 0.59), indicating that the reduction in PPD was greater in cases where the defect already existed and presented higher values. With regard to the maximum area of lesion opening (MALO), it was observed that although there was no statistically significant difference (P = 0.06), there was a tendency for this to occur. Therefore, Pearson's correlation coefficient was used and showed that this relationship tends to be moderately positive (R = 0.45), that is, the greater the value of the lesion area, the greater the reduction in probing depth (ΔPD). In the test group (surgery + EMD), no statistically significant differences were observed for all tomographic parameters in relation to the reduction in probing depth (ΔPD).Considering the reduction of probing depth (ΔPD) in the control group, it is possible to observe in P = 0.03), with moderately negative correlation (R = -0.5), that is, the larger the maximum area of lesion opening, the lower the gain in horizontal clinical attachment level (ΔHCAL).With regard to the horizontal clinical attachment level (ΔHCAL), only the test group showed a statistically significant difference in relation to the maximum area of lesion opening (P = 0.05) and defect height (P = 0.04) in relation to the reduction in probing depth (ΔPD), with Pearson's correlation coefficient showing a moderately positive correlation . This indicates that in larger volume lesions there was an increased tendency of reduced probing depth. Similarly, this behavior was also observed in the defect height when the groups were analysed separately , it was observed that there was a statistical behavior indicating that the larger this area, the greater the reduction in the probing depth . A possiIn the test group (surgery + EMD), the results were controversial regarding the correlation of tomographic parameters with the reduction of probing depth, since no statistical differences were observed in any of the variables. Some anatomical factors could have contributed to this result, such as lower frequency of infra-osseous defects in the test group compared to the control group. In addition, minor defects were more present in the test group than in the control group, a finding observed with analysis of primary data on an individual basis. Additionally, studies , 20 showIt is important to emphasize that the literature shows that EMD has no mechanical properties to assist proving space and stabilization of the clot (6), requiring a larger structure around the lesion. Therefore, the larger lesion volume observed in the test group may have impaired the periodontal regeneration process, although there are several studies in the literature showing its predictability , 20, 22.Some studies have been conducted by using this material in combination with other techniques , 24 to eAmong the limitations of this study, one can cite the patient's difficulty in maintaining proper oral hygiene and plaque control in the surgical sites, which may either directly or indirectly influence the results. Casarin et al.  used theWhen the two groups were analysed together , it was observed that the larger the lesion volume, the deeper the probing depth  and use of post-processing image filters improving evaluation of the measurement parameters.5The results of this study show that, among the tomographic parameters analysed, a greater height of IOD and a larger area of MALO suggest that there is a greater reduction in the depth of PD, especially in the control group. In the study group, a greater MALO tended to cause a greater gain in clinical insertion (ΔHCAL). Additionally, joint analysis showed that the volume of the largest lesion would be related to a greater reduction in the probing depth.B. Gonçalves: Conceived and designed the experiments; Performed the experiments; Wrote the paper.A. Costa: Conceived and designed the experiments; Analyzed and interpreted the data; Wrote the paper.R. Correa: Performed the experiments; Analyzed and interpreted the data.N. Andere and M. Santamaria: Performed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data.C. Ogawa: Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data.S. de Castro Lopes: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Wrote the paper.10.13039/501100001807FAPESP (São Paulo Research Foundation) .This work was supported by Data will be made available on request.The authors declare no conflict of interest.No additional information is available for this paper.


Participants provided a positive feedback regarding overall satisfaction  compared to service charge . The study demonstrated high AD completion when refusing LST or ANH. These findings may facilitate the development of ACP as a community-based service.Advance care planning (ACP) provides access to complete advance decisions (ADs). Despite the legalization of ACP in Taiwan, it is underutilized in community settings. The objective of this study is to describe the service at a community hospital in Southern Taiwan. We retrospectively analyzed participants who were engaged in ACP consultations from January 2019 to January 2020. The characteristics, motivations, content, and satisfaction of participants are reported. Factors associated with refusing life-sustaining treatments (LST) or artificial nutrition/hydration (ANH) were analyzed using multivariate logistic regression. Of the 178 participants, 123 completed the ACP. The majority were female (64.2%), aged 61 on average and more than 80% had never signed a do-not-resuscitate order. In the ADs, most participants declined LST (97.2%) and ANH (96.6%). Family-related issues (48.9%) were the most prevalent motivations. Rural residence (OR 8.6,  Patient Self-Determination Act in Western countries [Advance care planning (ACP) is a process that supports healthy individuals or patients in deciding their future care plans and wishes for end-of-life (EOL) ,2,3. ACPountries . Either ountries ,6. Validountries ,8,9,10. ountries . In geneThe Economist [Patient Rights to Autonomy Act in Taiwan, which enabled Taiwan to become the first place in Asia to legalize the ACP process and AD records [Hospice and palliative care services are accessible and mostly reimbursed by the National Health Insurance (NHI) in Taiwan. In terms of gradual improvements and awareness of health and palliative care, Taiwan ranks sixth in the world and first in East Asia in the Quality of Death Index as reported by conomist . The for records . ACP con records ,15. Busy records . Evidenc records ,18. HoweThe concept of ACP is largely derived from Western cultures, which leads to substantial obstacles in terms of distinct cultural perspectives. Gallagher et al. reported a survey of 2042 healthy participants in the UK and revealed that dying with dignity was the most frequently discussed and significant issue among all EOL wishes in the ADs . A systeDespite emerging studies confirming the feasibility of ACP consultations, participants’ characteristics, motivations, and outcomes in terms of satisfaction have been under-reported ,27. In aIn the present descriptive study, we retrospectively evaluated volunteer participants who had completed ACP consultations at a community hospital in Southern Taiwan. We elucidated the characteristics, motivations, content of the ADs, and associated factors for life-sustaining treatments (LST) and/or artificial nutrition/hydration (ANH). The definition of terms used in this study is presented in We enrolled volunteer participants for ACP consultations from January 2019 to January 2020 at the National Cheng Kung University Hospital, Douliou Branch, Yunlin, Taiwan. The study setting was a 200-bed community district hospital located in a suburban region of Yunlin County, which has a population of 0.11 million. In the study hospital during the identical time period, 23.2 cases registered a preference for palliative care at EOL and 122.1 outpatient visits were recorded in the collaborative palliative care clinics as a monthly average. Eligible participants had to be over 20 years of age with a clear consciousness, and voluntarily engage in consultations. We excluded participants if they (1) had signed any ADs previously, (2) had participated in an ACP consultation previously, (3) could not be assured of the self-determining mental capacity, (4) had poor performance status (Eastern Cooperative Oncology Group Performance Status ≥2), (5) refused or failed to cooperate with the screening or formal consultations, and (6) were referred to other hospice or ACP services, or failed to attend the screening interviews or appointments.The participants first contacted specially trained study nurses via telephone calls or websites to elucidate their demands. The study nurses responded in the form of a pre-consultation interview by telephone or online messages within one week. After screening, eligible ACP participants were scheduled for consultation in formal outpatient ACP clinics.The ACP consultations were held in an independent outpatient clinic at the study hospital, including a team of three alternating physicians specializing in palliative and hospice care , two study nurses, and two clinical social workers. Specialized training for delivering ACP services is mandatory for all professional staff. The Ministry of Health and Welfare accredited both training courses and formal AD documents. According to the new legislation, the participants were charged an out-of-pocket fee of NT$ 1500 to 3500 (US $51.1 to 120) for each session, which lasted at least one hour. A family member or friend of the participant was required to be present during ACP consultation for the purpose of shared decision-making. The AD documents were printed in traditional Chinese and permitted multiple choices or handwritten descriptions. The English-translated version is provided in The ACP consultation process included: (1) confirming the participant’s eligibility, preferences, and motivations for ACP; (2) detailed explanations of the five presumed medical conditions: terminal illnesses , irreversible comatose status , sustained vegetative status , severe debilitating dementia, and other unspecified agonizing illnesses ; (3) choosing to refuse or accept LST or ANH under each of the presumed medical conditions or assigning this decision to a healthcare agent (HCA) recorded in the ADs; (4) assigning EOL preferences and wishes in the ADs; and (5) evaluation of the participant’s understanding of and satisfaction with the session.We recorded the clinical and demographic characteristics of the participants, including sex, age, underlying illnesses, residential area, religious background, education, and antecedent preferences for hospice care or cadaveric organ donation prior to ACP. Van Wijmen et al. proposed various possible motivations for participating in ACP . Therefop-values less than 0.05, or clinically relevant as determined in the univariate analysis, were selected for the multivariate model. Statistical significance was noted if the covariates had a p-value less than 0.05. We used R 3.5.1®  and IBM SPSS Statistics 22.0  for data management and computing.We presented the clinical and demographic characteristics as descriptive analyses in the form of frequencies or percentages. Satisfaction scales were compared as matched and paired continuous variables using a Wilcoxon signed-rank test, with a prespecified two-tailed α of 0.05, to fit in the non-parametric assumption. Dichotomous univariate and multivariate logistic regression analyses were conducted for factors related to accepting LST and ANH in the ADs. All covariates were independent and tested for multiple collinearity and were excluded if violations were detected. Variables with n = 7; rheumatological disorders, n = 4) and 65.9% did not have any chronic illnesses. Very few participants had signed wills for palliative care, do-not-resuscitate (DNR) order, or cadaveric organ donation  (A flow diagram of the study is exhibited in ctively) .p = 0.019). Although a trend toward a preference for LST was observed in Scenarios 1 and 3, it did not reach statistical significance . Under prespecified conditions, where LST or ANH was conditionally accepted, LST as a time-limited therapeutic trial was requested by six participants with an average time of 3.0 months. Similarly, ANH was requested by eight participants with an average time of 2.6 months. Only one participant requested a HCA to handle medical directives under all scenarios except Scenario 3, where he signed a refusal.In terms of ADs, most of the participants declined LST (97.2%) and ANH (96.6%) . HoweverThe motivations for ACP consultations are presented in p = 0.005), increased age , and reluctance to consent to cadaveric organ donation  were significant independent factors correlated with refusing LST or ANH in this study population , 11 were lost to follow-up at six months, and six participants refused further evaluations of their level of satisfaction with the service. Among those who could be evaluated (n = 106), the overall satisfaction feedback revealed a generally high result  immediately after ACP consultation (n = 2), the need to simplify the process (n = 2), the intention of ACP to protect physicians from medical disputes (n = 1), and the futility of ACP in the presence of DNR orders (n = 1).From the total study population (ultation . Detailsp = 0.104).In the median follow-up time of 9.9 months, no participant from the study population had executed care plans based on their ADs. The interview six months after the ACP consultation revealed a trend of a decrease in overall satisfaction ; however, it was not significantly different from the initial assessment . To the best of our knowledge, this was also one of the novel studies since the enactment of the Patient Rights to Autonomy Act in Taiwan to confirm that delivering ACP services in a community-based institute instead of large-scale medical centers is in fact possible. A comparative study in Germany indicated that the completion of ADs in outpatients did not differ from that in either private practice or university clinics, in which only about one-third of the participants created a living will or assigned a HCA [The present study illustrated the characteristics of participants and their ADs based on a structured ACP consultation in empirical practice. We demonstrated a high completion of ADs (ed a HCA . Mansfieed a HCA . Hirakawed a HCA . Indeed,We observed that the most common motivation for ACP was family related issues. Participants did not want to become a burden on their family and developed their ADs based on their experiences with the death of family members. In addition, ACP frequently involved close family members, as 73.2% of the participants were accompanied by a first degree relative or a spouse. Boerner et al. reported that a well-functioning family and spousal support significantly facilitated discussions on ACP by an increased odd of 2.8 times . AnotherIn addition, we observed that service charge influenced motivation and satisfaction related to the choice to engage in ACP. Of the participants, 9.1% declined the service owing to the payment requirement, and 30.1% graded the charge as “poor.” Despite the wide availability of hospice services in Taiwan’s NHI, it is mandatory to charge a fixed price for ACP consultations . PellandThe participants in the present study were well-educated, with a generally high level of well-being, and functionally capable, with only 8.9% suffering from a major medical illness, and none presented with a hastened demand for EOL care at the consultation. Healthy individuals encounter several barriers to ACP compared with chronically ill or debilitated patients, such as prognostic uncertainty, lack of convenient services, younger age, and poor self-health consciousness ,42,43. AIn the present study, the participants presented distinctive values regarding LST and ANH. In the posited medical conditions, LST was not a preference and was regarded as an unnecessary invasive measure for sustaining survival of limited quality. However, ANH has been conditionally accepted as a time-limited trial. The attitude toward depriving hydration or nutrition may have been influenced by culture, since from an East Asian perspective, hunger and thirst are unnatural and agonizing while dying . FurtherWe further observed that participants were more likely to accept LST or ANH if they had consented to cadaveric organ donation. Whether the intention was to facilitate successful donations remains uncertain. A study in Germany revealed that living kidney donors had more adaptive personality traits, higher levels of agreeableness, higher motivation, and lower neuroticism scores than the general population . DespiteHamel et al. proposed that older age is associated with higher rates of ventilator decline, dialysis, nutritional support, and surgery, even after adjusting for medical conditions and preferences . On the The satisfaction outcomes of the study were generally positive. Respecting autonomy, length of the sessions, and understanding of ACP had received the highest ranks, with the exception of service charges. This reflected the reluctance of the participants toward out-of-pocket payments and their inadequate financial incentives. Zwakman et al. reported that ACP is associated with unpleasant feelings, positive responses, and benefits in hindsight . In the The merit of this study is that it was conducted in a community hospital where the medical resources are substantially limited and is one of the pioneers in the Taiwan region since the enactment of the new legislation. Further, we provide the participants’ views, including motivation, content, and degree of satisfaction, for further comparisons with other models. However, there are some limitations that should be considered. First, it was a retrospective single-center study with a small sample size that could not address interventional differences. Second, the participants were recruited by online information and represented a selected population with good education, high levels of health consciousness, high socio-economic backgrounds, and high motivation for study participation, which leads to selection bias and prevents extrapolation and generalization. Our future work will focus on expanding the participants to patients from outpatient clinics and inpatient units of oncology service and a comparison of participants from another affiliated urban tertiary medical institute. Third, viewpoints from physicians or other medical staff are not examined for this study. A qualitative exploration among all stakeholders is needed to elucidate the underlying factors that contribute to decision-making. Nevertheless, our results still provide deeper insight and essential information on a structured ACP consultation with high AD completion and illustrate the characteristics of the participants and their will.This study demonstrated high AD completion based on structured ACP consultation. The participants engaged in ACP largely due to family related issues. They also declined LST or ANH in general, yet ANH was accepted under some conditions. Non-urban residence, increased age, and reluctance to consent to cadaveric organ donation were associated with refusing LST or ANH. The service received a high satisfaction rank with the exception of out-of-pocket service charges. Together, these results may facilitate the development of ACP as a community-based service, which might be useful in the Asia-Pacific region due to comparable cultural characteristics.