The paper explores the benefits of global financial reporting models for developing countries, discussing the case of Romania, which, at the recommendations of the World Bank and the International Monetary Fund, exceeded the minimum requirements of the European Union, by imposing the full adoption of the International Financial Reporting Standards (IFRS) in individual financial statements of listed companies. Using regression analysis and decomposition techniques, the paper explores the evolution in value relevance of financial variables based on pre-(2009–2012) and post-(2014–2016) adoption samples, showing that after IFRS adoption financial information becomes significantly more relevant for equity valuations. We also provide empirical evidence showing that the degree of relevance for stock valuation, as well as the IFRS impact varies across types of firms. Overall, our findings tend to indicate the success of the financial reporting reform, which could be relevant for other jurisdictions facing similar decisions. Investors base their decisions on a complex set of information of various kinds, yet their primary interest lies in estimating the outlook for cash inflows of an entity that drives its ability to pay future dividends. In order to assess an entity’s ability to generate positive future net cash flows, investors need information on the entity’s economic resources and claims, but also on the efficiency and effectiveness of its resources administration. All this information is mainly financial in nature, and the companies’ financial reports are a major source of information for investors as they provide “much of the financial information they need” . TherefoAs a result of the need to increase the quality and comparability of financial information available on capital markets around the world, we are currently witnessing an unprecedented process of standardization of financial information. This process is led by the International Accounting Standards Board (IASB), which is a private independent foundation aiming at developing a single set of high quality, globally accepted rules: International Financial Reporting Standards (IFRS).i.e. removing barriers to cross-border investments, increasing the quality of financial reporting and reducing the cost of capital. These beneficial effects are expected to occur with greater intensity for countries with less developed economies, financial markets or local financial reporting systems. That is because, in addition to the adoption of a global financial communication language that facilitates investors’ access to local markets, the implementation of high quality accounting standards (such as IFRS) for such countries improves the quality of financial information, ensures transparency, reduces information asymmetry and risk, being a prerequisite for attracting and reducing the cost of capital.By implementing IFRSs globally, the IASB aims mainly at achieving three major benefits , i.e. ree.g. the World Bank and the International Monetary Fund) have conditioned, in many cases the provision of access to finance for such national jurisdictions, with the implementation of IFRS ).).i.e. thvalue relevance of accounting information, that is, by assessing the extent to which financial reporting comprises the relevant information that determine the companies’ value  . T. Tvalue elevance , 24]..value reet al. ..price leet al. , b, bet al.We first estimate value relevance based on net income and book value of equity  in parenthesis.2).We use stock market prices with a three months lag in order to allow prices to incorporate financial data, which is consistent with relevant literature . Value We are also interested in the value relevance of each individual financial variable addressed by this study, as well as in their combined contribution to stock valuation. Therefore, we also estimate Eqs All variables measured as per share data.Definition from Thomson Financial (TF) in parenthesis.et al. , a, a58], aIFRS adoption has no significant impact on the relevance of financial information reported by loss-firms. IFRS adoption has also no significant impact on the value relevance of accounting amounts reported by financial companies, with the exception of sales, which could be explained by the relative constancy in the transparency and quality of financial disclosure of these entities both before and after IFRS adoption. Another explanation could be the fact that banks already prepared IFRS compliant individual financial statements as a mandatory second set of accounts since 2009. This is obviously not the case for non-financial companies, for which the relevance of all financial amounts increased significantly in the post-adoption years.In terms of relative importance, book value of equity ranks first for all sub-samples except loss-firms, with net income ranking second for better performing companies (profit-firms and Premium tier companies), being the closest to book value of equity in the case of profit-firms (6.56% difference in terms of relative importance). Sales seem to matter more for financial entities and Standard tier shares, while cash holdings and dividends seem to count more for non-financial companies.et al. [The paper examined the changes is value relevance of financial information over time for an emergent capital market, showing that after the IFRS adoption in individual financial statements, accounting amounts become more relevant for stock market valuations. We used regression analysis and decomposition techniques for the total explanatory power of the models used in order to assess the magnitude of value relevance of financial indicators, as well as their relative importance. Following Barth et al. , we explWe find that all financial amounts investigated are significantly correlated with equity prices, and that their value relevance features increasing trends. Although increases in value relevance vary among the accounting variables analyzed, our results show that increases are significant after IFRS adoption in all cases.e.g. sales) in cross-data analysis, particularly for the beginning of our analyzed period. These results are found to be at odds with those reported for developed markets, where net income is the most value relevant, and are explained by the low performance of the Romanian listed companies, which drives investors to rely less on earnings and more on indicators that can help assess the companies’ ability to generate future earnings, or provide a proxy for liquidation value.In terms of relative importance, our findings show that book value of equity is the most relevant accounting amount, while net income ranks second, being even outranked by other financial data  but not for loss-firms. We also find that IFRS adoption did not significantly increased value relevance for financial entities.The main limitation of the paper comes from the relatively small number of observation compared to studies conducted on established markets, which is further amplified by missing data. However, as argued elsewhere , this isThis paper contributes to the literature by providing empirical evidence of the benefits of IFRS adoption on a developing market, showing that the IFRS adoption in individual accounts of listed companies led to an increase in value relevance. The paper also provides a more comprehensive perspective on the value relevance of a broader array of financial amounts, which is rarely done for emerging markets. Our results suggest that net income might not be the most relevant financial information on emergent markets, which may advise future research in this area to avoid focusing only on earnings, and also address other accounting amounts when exploring value relevance. An interesting development for future research on emergent markets could be providing empirical evidence on the actual roles played by different financial variables in stock valuations, and analyze the impact of IFRS adoption in the context of other drivers of value relevance.


Purpose: The community-based participatory research approach has been identified as a great asset in reducing health disparities through the integration of community members in all phases of the research process. It is essential to provide skills to community members to achieve successful research partnerships. The purpose of this study is to evaluate the feasibility, acceptability, and preliminary efficacy of the community-based participatory research training curriculum for community members.Methods: Using mixed-methods, noncomparative design, eight workshops were developed and tested. Workshops covered topics such as community-based participatory research principles, health disparities, ethics in community-based participatory research, and fundamentals of research methodology. A total of 25 community leaders were trained. Pre-/post-test knowledge (unpaired t-test), retention rate, workshop satisfaction, and cognitive debriefing sessions were used to assess knowledge gained and acceptability and feasibility of the curriculum.Results: A retention rate of 100% and an average satisfaction of 92.68% were obtained. Preliminary effectiveness results indicate that there was an overall significant change in participant's knowledge before and after the curriculum (p<0.001). In the cognitive debriefing, participants were satisfied with the organization and structure and found the curriculum feasible. Furthermore, participants identified the skills acquired to aid in being more effective in their communities and work with academic researchers. The following changes were recommended: workshops' order, time, practical activities, and level of language.Discussion: Findings from this study suggest that the curriculum was acceptable and feasible to community leaders and that it might provide skills to actively incorporate community members in research activities. A large randomized clinical trial (RCT) study to evaluate curriculum effectiveness is recommended. Furthermore, it supports existing and potential community-based participatory research projects.15 which is very important, if what has been previously stated to be of benefit to both the community members and academics is to be achieved. Although curriculums/programs have been created to teach community members about community-based participatory research and/or health disparities,16–20 to our knowledge, a curriculum that would provide Hispanic community leaders with a basic understanding of community-based participatory research, research, and health disparities has not been developed. Recent curriculum topics center on public health components, community-based participatory research components, or research components but do not unite all of these components together in a single curriculum.16–20 We identify community leaders, as defined by Community Tool Box, as people who take responsibility for the well-being and actively participate in the improvement of their community.22Little work has been done in pinpointing ways to reduce barriers for community members to fully participate in community-based participatory research,To address the existing knowledge gaps, a curriculum  to train Hispanic community leaders in community-based participatory research principles and basic research concepts was created. The primary goal of the community-based participatory research training for community leaders was to develop an innovative curriculum aimed at forming a new generation of community leaders skilled at engaging in community/academic research partnerships for the elimination of health disparities in our communities. The purpose of this article is to report on the development and creation of a curriculum and evaluate not only its feasibility and acceptability but also the knowledge gained (preliminary effectiveness) by the community leaders.The researchers conducted a mixed-methods pilot study to assess a community-based participatory research curriculum for training community members. The Institutional Review Board approved the study protocol at the Ponce Health Sciences University.Inter-Professional Perspectives of Health Disparity course23 at Ponce Health Sciences University were considered. Finally, the topics that were selected to comprise the curriculum were presented to three experienced researchers in the community-based participatory research approach, which suggested the six topics in A review of the literature showed common themes regarding community-based participatory research principles as they apply to research. Also, themes included in the Experts on the topics and who had extensive academic/community experience were recruited to give the workshops. They were given a rubric to establish uniformity between the workshops, which included assigned topics, objectives of the workshop , practical activities, and questions to be used to evaluate knowledge gained (including the number of questions and the issues to be considered when writing those questions). Before being presented, workshops were revised to ensure the suitability of the established objectives.24 , which is a government-based initiative that seeks to empower underserved and socioeconomically disadvantaged communities in Puerto Rico as a way to promote self-management. Participants in the study represented various communities and community-based organizations  on the south side of Puerto Rico and were active community leaders.Purposive sampling was utilized to recruit 25 community leaders from the “Programa de Comunidades Especiales”Special Communities Program; there, we presented the goal, objectives, and purpose of the project. An invitation letter to the forum was sent to 40 community members that met inclusion criteria: (a) be 21 years or older, (b) have completed at least a high school education, (c) voluntarily have consented to participate in the workshop training, (d) be a designated community leader of the Special Communities Program southern side, (e) express interest in learning about community-based participatory research activities, (f) express interest in becoming a community research leader, and (g) express availability/commitment to attend all the workshops and complete the cognitive debriefing tool. After presenting the community-based participatory research curriculum objectives and activities, we invited community leaders to participate in it, see A community forum was held to recruit leaders from the The curriculum consisted of eight workshops, facilitated by academics with broad knowledge of community-based participatory research-related topics. All the workshops consisted of interactive group sessions, didactic session (4 h), and practical activity (1 h), which included the following topics: community-based participatory research (two sessions), fundamentals of research methodology (two sessions), work ethics in community-based participatory research, health disparities, translational research, and social determinants of health. Workshops were held from December 2016 to April 2017 (one or two sessions/month) at Ponce Health Sciences University.To assess the acceptability and feasibility of the curriculum, the participants completed a cognitive debriefing session at the end of every workshop. Each session included questions exploring general thoughts, content, confusion of content, speaker style, controversial topics, practical activity, and readiness to educate the community.Debriefing 26 In this study, it was utilized to evaluate the feasibility and acceptability of the curriculum and the topics presented to the participants and to improve the quality of the workshops. At the end of every workshop and implementation period, the participants had a cognitive debriefing led by a trained interviewer. The final cognitive debriefing at the end of the implementation period was done in four smaller groups with five to six participants and was centered more specifically on the curriculum as a whole. The questions used for the cognitive debriefing were designed in a semistructured format, and each session lasted from 30 to 60 min, depending on how actively the members participated. Suggestions from the cognitive debriefing sessions after the workshops were reviewed and utilized for later workshops.Cognitive debriefing is the process by which an instrument is actively tested with representatives of the target population and target language group to determine if the respondents understand the material.Recordings were made of every group session, so they later could be transcribed. Two research assistants independently reviewed and analyzed the contents of the recordings. Themes and responses that were repeated during the various workshops and at the end of the implementation period were noted. After independently reviewing and analyzing the contents, researcher assistants categorized those contents, and any conflicting codes that were found were discussed by the two research assistants and the principal investigator. The principal investigator decided on the final coding after this discussion.Retention rate27 In this study, the term “retention” refers to the completion of six or more workshops by the participants and “dropout” to describe participants who decided to discontinue workshops and/or who completed five workshops or fewer. The retention rate formula is as follows:High retention rates are important to maintain the internal validity of a study, especially when working with a cohort.SatisfactionThe participants, at the end of each workshop, evaluated that specific workshop for satisfaction through an evaluation form with a 5-point Likert scale. The two highest points were consolidated and considered satisfactory.Knowledge gained (preliminary effectiveness)t-test analysis. The pretest and post-test were assigned group 1 and 2, respectively, for the analysis.Before and after the didactic session, participants were administered pre- and post-tests to evaluate the knowledge acquired from the workshops. Each lecturer created between 5 and 10 multiple choice questions using, as reference, the information presented in each of the workshops; the questions were presented to and approved by the principal investigator to verify comprehensibility of language and fidelity of rubric. IBM SPSS Statistics (version 24) was utilized to assess the change from pretest to post-test using unpaired Retention rateDuring the implementation, no dropouts were evidenced resulting in a retention rate of 100%.SatisfactionWorkshops were given a more than 85% satisfaction rate, and individual rates of the workshops are as follows: community-based participatory research , fundamentals of research methodology , work ethics in community-based participatory research (96%), health disparities (100%), translational research (86%), and social determinants of health (92%). The overall satisfaction of the workshops was estimated at 93%.Cognitive debriefingSee t-test results indicate that there was a change in participants' knowledge after four of the seven workshops in which a pre-/post-test was administered as seen in Unpaired Cognitive debriefingIn the cognitive debriefing sessions, acceptance and feasibility were evaluated using guided questions. Results obtained indicate that participants accepted the curriculum, as the retention rate achieved was 100.0%. Furthermore, participants in the evaluation forms at the end of every workshop reported that they were satisfied with the workshops; a 92.7% overall satisfaction rate was obtained. In their answers to the cognitive debriefing questions related to the acceptance of the curriculum, participants expressed the opinion that some of facilitators used language that was too technical to easily absorb when presenting workshop topics, which should be taken into consideration for future workshops. They also suggested that some workshops need to be given more time or be divided into more sessions and suggested, as well, that the order in which they are given be changed. For example, participants pointed to the methodology workshop as being one that would benefit from more time (to aid understanding); they also recommended that the research-related workshops be placed after those dealing with socioeconomic topics, as the latter is more immediately relevant.29 all of which have impacted many communities, including the ones to which our participating leaders belong. Being aware of this, they could see an opportunity to acquire additional tools and utilize the knowledge they gained, as they were taught that community-based participatory research helps create meaningful scientific investigation, which in turn yields science-based knowledge for broader based social action/change that is intended to benefit their communities. This echoes with the Hispanic values of familismo, which places high value on family (both nuclear and extended), and altruismo, which is the disinterested concern for the well-being of others based on love or caring.31 We recognize these characteristics as being associated with one the of community-based participatory research principles, which is to recognize the strengths and assets of the community.4 These values, being characteristic of the Hispanic population, could increase both the impacts of the overall satisfaction and acceptability of the participants with the curriculum. Other training programs demonstrate findings such as ours, in which, as a result of their participation in said programs, additional tools were obtained by members, which aided them to change their communities for the better.12The participants found the curriculum to be well organized and structured, and the workshop topics and the materials given were pertinent and useful to the leaders, not only when they worked with the researchers but also when they were out working in their communities. In every workshop, materials were given, such as PowerPoint handouts and scientific articles. These were identified as being useful, although the participants also mentioned that such materials could be sent electronically (via e-mail) so that each could peruse said materials on their personal computers/smartphones. Acceptability and satisfaction indicators demonstrate that the curriculum resonates with the community leaders, as indicated by the results in their evaluations of the workshops, but this resonance can also be attributable, at least partly, to Puerto Rico's socioeconomic reality. The island's health system and economy have experienced challenges and a decline in the last few years,p<0.05). Three workshops were not statistically significant: fundamentals of research methodology  and community-based participatory research (p>0.05). Three of the workshops that yielded statistically significant results covered areas in the social sciences , and one covered an area in the basic sciences . The topics encompassing the social sciences appear to be easier to retain, as the material is relatable to the leaders' daily lives. Assimilation theory confirms this, as it states that the acquisition of information from presented learning material requires a meaningful learning set and the demonstration of potentially meaningful material, later necessitating that a given learner's cognitive structure contains relevant anchoring ideas to which the new material can be related.32 Although translational research is basic science and our participants achieved significant changes in their knowledge, this could be attributed to the applicability of it regarding their being able to use it to help their communities, as the curriculum involved bringing information from laboratories to the community.32 Any lack of relatability may have affected the retention of topics such as fundamentals of research methodology, which is a research topic that may not be recognized by leaders as a direct vehicle to help the community, and community-based participatory research, which is a research and social sciences topic that presents the integration of community members as part of the research team; in this, the research methods and roles they will acquire during such a process when participating in community-based participatory research are relatively new to community members, which might explain the lack of change in knowledge in the workshop.32 The utilization of a practice session at the end of every workshop can further explain positive results; the participants commented that these sessions aided them to solidify their understanding of the material, which, we understand, is related to their being able to familiarize themselves with the content. As previously mentioned, workshop topics were based on topics deemed relevant by our sample population, which relatability also aids in their retention of knowledge and is confirmed by the overall knowledge gained (p<0.00).32 Still, taking into consideration all of the recommendations of the participants and the results obtained, a refinement in the structure of the workshops needs to be made. Suggestions with respect to future workshops include lengthening the duration of the workshops (which could be divided into 4 h of theory and 2–3 h of practice sessions), dividing such topics as community-based participatory research and fundamentals of research methodology into at least three to four sessions, respectively, and sending workshop materials electronically to better accommodate the needs of the participants. Our results are like those of a training program whose participants also expressed their desire that the training be extended, or topics spread across more sessions. A strategy utilized by the same program to help participants solidify knowledge was to give homework assignments, which 88% felt were useful and 73% claimed helped them to understand the material11; this strategy can be utilized to help participants solidify their understanding of the workshop topics, especially the ones in which there was difficulty.The preliminary effectiveness of the curriculum was measured as knowledge gained; out of the seven workshops analyzed, the knowledge acquired by participants in four of them was found to be statistically significant , “It is the first time in all my years working with the community that I have received any training like this; that is, I have been in lots of workshops and they talked about many good topics but that they [the current workshops] were so precise, so clear, so specific, at least for me, it was the first time.” The participants also mentioned improvements, such as extending existent sessions or dividing the topics into more days and increasing the practical activities of each topic.16–20 ours is, to our knowledge, the first curriculum tailored to Hispanic community leaders that integrates various topics. This curriculum may aid in integrating community members more effectively in research activities that will support in creating meaningful studies for the communities they impact and ultimately assist in increasing health equity through community-based participatory research. The strengths of the study include utilization of a mixed methodology and obtaining a participant retention rate of 100% during the implementation period. Limitations of the study include participation of leaders, only, as they have an extra motivation to participate in this type of workshop. Furthermore, the statistical methodology may have been more rigorous if we had used paired t-tests to analyze the knowledge gained. Being that this was a pilot project intended to ascertain the preliminary effectiveness of the curriculum, future studies should aim to evaluate effectiveness using a randomized controlled trial to obtain generalizability of results.The primary objective of this article is to report the development of a curriculum and evaluate its feasibility, its acceptability, and the knowledge gained by community leaders. The study findings affirm that the curriculum is feasible and acceptable. Furthermore, it supports the preliminary effectiveness of the curriculum concerning improving the knowledge of community leaders. Although other curriculums have been created to capacitate community members about community-based participatory research, health disparities, and research,


The effect of microstructure on macroproperties of building materials was the initiation in order to use microscopic techniques for studying the materials' behavior. Primer role among the different techniques has the scanning electron microscope (SEM) as it provides much information in an easy and understandable way. SEM has been used in almost every study of the last decades, dealing with historic and repair materials to complete the analysis performed. In the case of historic mortars, it is a unique technique as it requires a small representative sample and without any intense treatment important information derived from an almost unknown sample including damage detection, phase identification, and microanalysis. It is usually a complementary method of analysis but a precious one as the gained results from the analysis of old mortars are used for designing compatible repair materials for restoration purposes. In the paper, the long-term use of SEM in studying both old authentic and innovative repair mortars is presented. Microscopic analysis of material's structure is valuable for many applications, such as the material's development and improvement, quality control, reverse engineering, and evaluation of performance . The comμm) than that for a secondary electron image (10 nm). Because of their greater energy, backscattered electrons can escape from much deeper regions of the sample than can secondary electrons, hence the larger region of excitation. The formation of the images depends upon the acquisition time selected and varies from a few to several minutes.A second type of electrons, the backscattered electrons, is also produced when the specimen is irradiated with the primary electron beam. Together, backscattered and secondary electrons contribute to the signal that reaches the scintillator and form what we refer to as the secondary electron image. A backscatter electron is defined as one which has undergone a single or multiple scattering events and escapes with an energy greater than 50 eV. Backscattered electrons are produced as the result of elastic collisions with the atoms of the sample and usually retain about 80% of their original energy. The number of backscattered electrons produced increases with increasing atomic number of the specimen. The region of the specimen from which backscattered electrons are produced is considerably larger than that for secondary electrons, and the resolution of a backscattered electron image is considerably less . By analyzing the characteristic X-rays generated, the elements that constitute the specimen can be identified and this creates the qualitative and quantitative elemental analysis of the surface detected. Additionally, their position can be recorded or “mapped.” These X-ray maps can be used to form an image of the sample that shows where atoms of a given element are localized. The resolution of these X-ray maps is on the order of greater than 1 Scanning electron microscopy requires electrically conductive specimens. Insulating specimens need to be covered by a thin (1–10 nm) conducting surface layer, usually applied by sputtering with gold in an argon atmosphere, or with carbon coating in vacuum. Sample size can be a maximum of 10 cm in diameter and 50 mm in height, but there is a restriction in the specimen's movement, so the area of interest should be about 2.5 cm in diameter around the center of the goniometer stage. Restrictions also apply regarding the maximum height, tilt, and rotation, depending on the specific stage.The above characteristics make SEM with X-ray microanalysis very effective in morphology investigation, as easily produced micrographs provide topographical information together with the qualitative and quantitative analysis, evaluating the characteristics of the materials. The SEM used for this study is a JSM 840 A, assisted by OXFORD INCA EDS analysis and applied both on old historic mortars in order to understand their nature as well as on repair mortars in order to record the achieved properties.The abovementioned characteristics of the SEM can be utilized in order to analyze the heterogeneous mortars' structure. The study of an old mortar, taken from a monument or historic building, is usually a “black box” as no data can be obtained from any source . Approaching the physical, mechanical, chemical, and mineralogical properties of old mortar, aiming to decode its behavior into the structure, requires combined techniques  , 6. To uThe aggregates used in old mortars were usually natural in origin, while crushed ceramic or limestone pebbles in various granulometries with even distribution were also used in some cases , 14. TheBecause of long exposure, old mortars develop different pathology symptoms such as cracks, crumbling, and erosion . To studSEM is also used for the study of porosity since it has high resolution limit allowing a wide range of pore sizes to be recorded and the geometry can exactly be described .μm [By measuring, the area of voids from micrographs taken from historical mortars, qualitative and quantitative results of the damaged area, and the materials used can be estimated. Also, the porosity influences the macroscopic properties of the mortars and it is strongly correlated with the material's decay process. The uniform pore distribution recorded in old mortars allows some flow of water inside the structure without being held there. The porosity that characterizes old mortars (20–40%) is mainly due to micropores of 0.1–1 μm . Cracks The microscopic study of ancient mortars reveals that apart from the main ingredients, binders and aggregates, there are other materials as well, in small percentages in the mass, such as shells, charcoal particles, lime lumps, chips of wood, or straw . These eSEM and EDS analysis of mortars indicated the presence of organic fibers and calcite, quartz, and muscovite minerals of Ottoman mortars . This reSecondary recrystallization phases are often observed in the structure of ancient lime-based mortars. They are mainly situated in previously formed cracks, in spherical pores, and in the loose transition zone . The comSEM analysis performed in historic mortars reveals that the most durable mortars combine natural and brick aggregates with smooth granulometry, in the presence of few coarse grains and low proportion of fine aggregates in combination with strong binders. In the old mortars, the high proportion of aggregates is not always a quality criterion. Application of different aggregate/binder ratios, depending on the location of the mortar in the structure, the type of binder, and the construction environment, as applied by the old craftsmen, seems to have had many positive results in durability and quality of mortars. The combination of higher-quality lime with reactive natural pozzolan formed a strong binding system consisting of micrograined well-connected crystals.In order to design new repair mortars, many parameters are taken into account, such as the properties of old mortars, the use of proper available materials, the structure itself, and its environment . Principline scanning performed across the contact zone between different materials is also a powerful tool explaining the material's behavior in terms of strength and porosity (The energy dispersive X-ray porosity .Modern approaches in order to produce “smart” mortars which retain their traditional character but exploit new technologies for improving inherent weaknesses are of great interest in the last decades. Nanotechnology, for example, gave important products which have been successfully introduced in many traditional applications and improved mortar performance , 32. TheAlso, the role of additives in self-healing properties can be uniquely detected and identified and analyzed as healing products. That means that the morphology, place of growth, and stoichiometry of the formed products can be revealed, and the effectiveness of the healing process can be estimated  Figure .μm or nm permits the detection of inherent defects, as well as ageing or deterioration effects, which influence the material's behavior. The pieces of information taken contribute to mortar quality estimation, by quantifying the mass density, topography of pores and cracks, distribution of aggregates, and additions in the binder and density of binder-aggregate interfaces. The ability of penetrating deeper and having a direct observation of the structure, in the scale of micro or nano, allows detection of inherent defects, as well as ageing or deterioration effects, which determine the material's macroscopic behavior. SEM is an irreplaceable tool in order to understand the structure of mortars, both through image observation and also through the provided analysis. The study of building materials has benefited greatly from SEM and that in an extent explains the long-lasting use of it in material research and the need to further evolve the technique. The understanding of old mortars and the evolution of building materials, in order to cover different construction needs, was in a significant extent based on it. In this way, compatibility with the authentic structures could be achieved, but also new technologies could be tested, in order to assist towards mortar's durability. The latter seems crucial in order to produce innovative traditional mortars, preserving the principles of compatibility with increased durability. Through SEM possibilities, the reveal of ancient mortars was possible and the puzzle of missing information, explaining the behavior of the materials, was enlightened. Working directly on images and at the same time having quantitative data on the composition were a revolutionary practice that was widely applied for producing high-quality mortars that can be safely used for repair works and also plan the future for high-performance materials.The detrimental role of microstructure in the macroscopic properties of building materials and in mortars, in particular, is well known. To fully benefit from microstructure control, it is important to properly apply the full range of available microscopic techniques. Microscopes have been proven valuable tools to researchers, in order to detect damages, identify phases, and develop improved materials used in the construction field. A number of analytical techniques are needed to be combined for the complete characterization of historic mortar; scanning electron microscopy highlights the diversity of microstructures through direct observation and microanalysis as well. The possibility of penetration into the structure having a direct observation in the scale of


To compare the maternal and neonatal outcomes of patients with emergency versus therapeutic cerclage.The study included 38 female patients who underwent cervical cerclage using the modified Shirodkar method in the Obstetrics and Gynecology Clinics of Düzce University Medical Faculty Hospital and Düzce Atatürk State Hospital.The operating time for the emergency cerclage group was significantly longer than that of the therapeutic group . Following the cerclage procedure, the cervical length was longer in the therapeutic cerclage group . The cerclage to birth interval was also longer in the therapeutic group (91 vs. 138 days).In comparison with therapeutic cerclage, the total duration of pregnancy after emergency cerclage is shorter, and newborns have a greater need for intensive care. Both methods, however, protect against advanced prematurity, which causes neonatal loss. PRECIS: Both cerclage methods administered by experienced surgeons in appropriate patients could be effective.,2. There is a negative correlation between gestational age at birth and mortality and morbidity, primarily due to respiratory distress syndrome, intraventricular bleeding, necrotizing enterocolitis, and sepsis,4. Several factors are responsible for the etiology of preterm labor. One of these is cervical incompetence, which is seen in two percent of all pregnancies, and which leads to miscarriage in the second trimester and early third trimester,7.Preterm labor and the resulting preterm births remain a major problem for physicians, and despite all the advances made, it remains the leading health problem in the field of obstetrics in both developed and developing countries,9. The cervical cerclage procedure can be performed transvaginally with the McDonald and Shirodkar methods or transabdominally,11,12. The efficacy of these methods in therapeutic and emergency cerclage is controversial, but the McDonald type of cerclage is more widely used because the application is easier to perform,14.During the last 50 years, cervical cerclage has been frequently used to prolong the period until birth in pregnancies with cervical incompetence. In patients with cervical dilatation with or without prolapse of the amniotic membranes into the vagina, the procedure is conducted as an emergency cerclage. If cervical shortening is seen on serial ultrasonography measurements, the procedure can be conducted as a therapeutic cerclageThe aim of this study was to evaluate the maternal and neonatal outcomes when modified Shirodkar cervical cerclage was performed as an emergency or a therapeutic procedure in a three-year period in two clinics.This retrospective case-control study included 38 pregnant women who were diagnosed as having cervical incompetence and treated with cervical cerclage using the modified Shirodkar method. The patients were treated in the Obstetrics and Gynecology Clinics of Düzce University Medical Faculty Hospital  and Düzce Atatürk State Hospital  between June 2015 and May 2018.Approval for the study was granted by the Institutional Ethics Committee, and all procedures were performed in accordance with the 1964 Helsinki Declaration. Informed consent was obtained from all study participants. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.The therapeutic cerclage procedure was administered to patients with a cervical length of less than 25 mm without cervical dilatation in the second trimester sonographic cervical examination. The emergency cerclage procedure was performed on those with cervical dilatation determined during physical examinations and/or prolapse of the fetal membranes into the vagina.3), and a C-reactive protein level greater than 2.0 milligrams per deciliter (mg/dL)], as well as those who had preterm premature rupture of membranes, a fetus with anomalies, a history of cone biopsy and loop electrosurgical excision procedures, mechanical dilation of the cervix during pregnancy termination, and uterine malformations were excluded from the study. A 12-hour waiting period was imposed before performing cerclage in order to exclude patients with preterm deliveries.Patients with symptoms of clinical and biochemical chorioamnionitis . Cervical dilatation was not seen as a risk factor for preterm delivery before 32 gestational weeks .The data obtained in this study demonstrated that the cervical cerclage procedure (whether therapeutic or emergency in nature), conducted because of cervical incompetence in the second and early third trimesters, is effective in preventing extreme pre-term births. In the therapeutic cerclage group, the time from the procedure to birth was longer than when the procedure was performed under emergency conditions. Furthermore, the residual cervical length after the cerclage procedure was longer in the therapeutic group. With cervical lengths after cerclage that were shorter than 20 mm, vaginal contact with the amniotic membranes and multiple pregnancies were significantly more prevalent in patients who delivered preterm before 32 gestational weeks.  suggested that cervical lengths could be observed with transvaginal ultrasounds in women with a history of pre-term births because of cervical incompetence, and that emergency cerclage should be applied only if a short cervix was determined. In contrast, Guzman et al.  reported that better results were obtained with therapeutic cerclage as compared with emergency cerclage. In the current study, the cerclage to birth interval was more favorable in the therapeutic cerclage group. There was a lesser need for neonatal intensive care after birth in the therapeutic cerclage group, but there was no difference between the groups in terms of the neonatal mortality rate.Berghella et al.. In the current study, although the rates of membrane rupture associated with the procedure and chorioamnionitis after the procedure were higher in the emergency cerclage group, the difference between the groups was not statistically significant.Therapeutic cerclage is generally applied early in the second trimester and is a relatively low risk operation. An emergency cerclage procedure is applied more typically in the middle of the second trimester, when the cervix is significantly shortened, when there is cervical dilatation and when membranes are prolapsed into the vagina; therefore, it is an operation in which complications such as membrane rupture and chorioamnionitis are frequently seen  found that 10% of patients maintained the pregnancy beyond the 37th gestational week. In a study by Ohad et al. , the results of patients having had the McDonald procedure as a therapeutic or an emergency procedure were compared, and 64% of the therapeutic group and 59% of the emergency group gave birth after the 37th gestational week. In the current study, the rate of births in the 37th gestational week or later was 62.5% in the therapeutic group and 13.6% in the emergency group. Ohad et al.  applied the emergency cerclage procedure to patients with cervical lengths of less than 25 mm in the second trimester. In the current study, all patients in the emergency cerclage group had cervical dilatation and/or prolapse of the amniotic membranes into the vagina. Contact between the fetal membranes and the vagina increases the risk of chorioamnionitis and intra-amniotic infections. These infections are sometimes clinically evident, and some continue as subclinical infections and trigger pre-term labor,20,21. This can be considered to be the reason for the high rate of pre-term births in the current study’s emergency cerclage group. At the same time, when the cervix has shortened to an advanced degree, and the amniotic membranes have prolapsed into the vagina, it is extremely difficult to place the cerclage suture at the level of the internal cervical os. Thus, it is clear that the efficacy of sutures that have not reached a sufficient length will be reduced. In comparison with the therapeutic group, the fact that sutures could not be placed in the appropriate position in the emergency cerclage group can be considered to be one of the factors that prevent the pregnancy from reaching full-term.In a retrospective analysis of 158 patients treated with the McDonald method, Zhuve et al.. However, very few studies have compared the efficacy of the application of different procedures. Obido et al.  found no difference between the McDonald and Shirodkar procedures in the prevention of pre-term births. In contrast, Treadwell et al., and more recently, Wong et al., reported that the Shirodkar procedure was more effective than the McDonald procedure in terms of preventing pre-term births. In a review published by Berghella, it was stated that the residual cervical length after cerclage should be greater than 2 cm to be effective in the prevention of pre-term birth; therefore, the cerclage suture must be applied as close as possible to the internal cervical os. Accordingly, to get as close as possible to the cervical os, it is necessary to dissect the bladder. In this respect, the Shirodkar procedure has an advantage over the McDonald procedure in reaching a satisfactory cervical height. In the current study, the Shirodkar procedure was applied to all patients, whether therapeutic or emergency, and in comparison with the McDonald procedure, there was considered to be a greater contribution to residual cervical height. There was also better support of the cervical tissue.The cervical cerclage technique has been used for more than 50 years in the prevention of pre-term births associated with cervical incompetenceThe strength of the study is that it is one of few studies that have compared the results of emergency and therapeutic cerclage procedures. Moreover, because the procedures were applied by surgeons experienced in this field, this standardized the applications. Basic limitations of the study include that it was retrospective, that there were relatively few patients, and that there was an insufficient number of vaginal cultures taken before the cerclage procedures.In conclusion, despite the advances that have been made in obstetrics, pre-term births remain a major problem. In the prevention of pre-term birth as a result of cervical incompetence, both therapeutic and emergency cerclage procedures are effective. However, it must be noted that with regular screening of the cervical length from the second trimester onward in high-risk pregnancies, this procedure should be applied before cervical dilatation and prolapse of the amniotic membranes into the vagina.


Obesity is a noncommunicable disease that affects a considerable part of humanity. Recently, it has been recognized that gut microbiota constitutes a fundamental factor in the triggering and development of a large number of pathologies, among which obesity is one of the most related to the processes of dysbiosis. In this review, different animal model approaches, methodologies, and genome scale metabolic databases were revisited to study the gut microbiota and its relationship with metabolic disease. As a data source, PubMed for English-language published material from 1 January 2013, to 22 August 2018, were screened. Some previous studies were included if they were considered classics or highly relevant. Studies that included innovative technical approaches or different in vivo or in vitro models for the study of the relationship between gut microbiota and obesity were selected after a 16-different-keyword exhaustive search. A clear panorama of the current available options for the study of microbiota’s influence on obesity, both for animal model election and technical approaches, is presented to the researcher. All the knowledge generated from the study of the microbiota opens the possibility of considering fecal transplantation as a relevant therapeutic alternative for obesity and other metabolic disease treatment. Obesity is one of the most alarming diseases of the 21st century. The World Health Organization (WHO) has reported that more than 1.9 billion adults around the world are overweight and nearly one-third of such individuals are obese [Gut microbiota is the set of bacteria, fungi, and protozoans that colonizes the digestive tract in a symbiotic consortium that has been recognized as a complex system that contributes to the physiological processes of the host. Recently, gut microbiota has been described as a fundamental factor in the triggering and development of a large number of pathologies, among which obesity is one of the most highly related to the processes of dysbiosis, including the relationship with the diversity and quantity of phyla such as Firmicutes and Bacteroidetes .Unfortunately, studying obesity and microbiota directly in humans is extremely difficult due to challenges of controlling variables in study subjects such as diet, medication, and genotype, as well as obstacles regarding the obtainment of samples and measurements. Thus, the first phases of research usually rely on in vitro or nonhuman in vivo models, in order to acquire a mechanistic understanding of the microbiome and obesity relationship. This review focuses on the main animal models and methods used to study human gut microbiome characteristics and their impact on obesity and metabolic diseases.The microbiota is implicated in diverse aspects of human health, including gut and immune development, energy balance, resistance to infections, and the processing of foreign compounds. Many of these associations have been made through studies in animal models in which the presence or composition of the microbiota could be manipulated. Microbiota contributes to host phenotypes. For example, many diseases are frequently related to perturbations in the microbial community, and its modification, for example by nutraceutics as phytochemicals, can be prophylactic for the prevention or treatment of obesity and inflammatory diseases . The utiSimple multicellular organisms provide an opportunity to identify evolutionary conserved features of the host–microbe relationship with a reduced complexity compared to mammals. For instance, these relationships may be represented by less than 50 species per host in simple multicellular organisms .Hydra belongs to the phylum Cnidaria and is considered a phylogenetically basal model with a simple body, a limited number of cells, nervous and immune systems, and a tube-like body with spontaneous contraction that resembles a mammalian intestine [Drosophila and Caenorhabditis [Hydra include the possibility of performing germ-free, gnotobiotic, or bacteria-specific models, its transparent body, its fast life cycle, and its easy cultivation, all of which make it a good model for the study of metaorganisms and interactions with hosting bacteria. The main bacteria present in Hydra can be cultured and Deines et al. proposed an in vivo and in vitro system of studying the interactions within the microbiome in Hydra, which provided insights into how the host affects intermicrobe interactions and vice versa [The ntestine . Disturbntestine . It alsohabditis  and is ahabditis . The bence versa .Apis mellifera) hosts eight bacterial species in its gut, with Snodgrassella alvi and Gilliamella apicola being the most abundant, that are transmitted between individuals through social interactions [The microbiome in the gut of vertebrates is represented by only a few phyla, but there is considerable intraspecies variation . In manyractions . Howeverractions .Lactobacillus apis group, which suggests that different evolutionary lineages with different functional roles  compose the intraspecies diversity of the gut microbiota [How the honeybee gut maintains its intraspecies diversity remains unknown, and the distribution of the microbe diversity within a honeybee colony has not been deeply studied. A simple explanation for the observed stable coexistence is that despite bacterial strains from the same species, they occupy distinct functional groups in accordance with nutrients or different types of diets. In that respect, data from metagenome studies in honeybees have shown different sublineages being present within the crobiota .Danio rerio) is an omnivorous freshwater teleost with many shared features of its digestive tract with mammals and is described as a model for studying microbiota interactions and their impact on host nutrient absorption, metabolism, the immune system, and intestinal epithelial functions [Fusobacteria during adult ages [The zebrafish  devoid of microbes that are resistant to body weight increases induced by diet compared to conventional animals. Several lines of evidence have shown a relationship between metabolism in GF mouse models and their microbiota .In 2004, Bäckhed et al. established that the energy yield and storage from the diet in hosts are affected by the microbiota. They observed that colonization of GF C57BL/6 with microbiota from the caecum of normally raised mice resulted in reduced food consumption but triggered the development of insulin resistance and body fat increases within two weeks. In addition, they identified that the suppression of fasting induced adipose factor (FIAF), a protein essential for the induction of disposal of triacylglycerols in adipocytes through microbiota signals . PolysacAlthough gnotobiotic technologies for GF animals have been explored since the 1950s , the useAkkermansia muciniphila establish the mucus-degrading ability of this bacterium and its capacity to produce short chain fatty acids (SCFAs), which stimulate microbiota interactions and host modification that protects intestinal integrity from pathogenic bacteria [Bifidobacterium longum BB536 interactions with the microbial consortium on the gut luminal metabolism [GF mice in gnotobiotic models can be colonized by single, specific types of bacteria to study mono-associated situations or can be colonized by two or three specific bacterial types to generate a simplified microbiota. GF mice can also be transplanted with culture collections or human fecal microbiota to investigate functions of complex human-derived microbiota. For example, research using GF mice transplanted with human microbiota has shown that cross-feeding activities of bacteria . The heatabolism . It is itabolism .Lactobacillus species represent 10%–15% of the rat microbiome: The rat microbiome is rich in uncharacterized anaerobic fusiform-shaped bacteria and segmented filamentous bacteria [Faecalibacterium is a bacteria present in the healthy human intestine, but which displays a very low abundance in the healthy rat intestine [The rat was the first mammal to be employed as an animal model for scientific purposes. The bacterial phyla in a healthy rat gut are similar to those in human and mouse guts, hosting Firmicutes, Bacteroidetes, Proteobacteria, and Actinobacteria, but the differences compared to those of humans should be considered. For instance, the large intestine of the rat presents a more complex environment, with rat feces having 2–3 times the bacterial diversity compared to human feces . Lactobabacteria . Faecalintestine . Despite these differences and other disadvantages such as elevated costs and more difficultly in their manipulation compared to mice, rats are good models for specific pathogen-free (SPF) experiments because their gut microbiome can be established under conventional or SPF conditions after the introduction of certain controlled environments : They haLactobacillus and Bifidobacterium spp. is different in abundance between rodents and humans [The use of rodent animal models is useful for many objectives, providing models with low costs of breeding, feeding, and handling, but their use has some disadvantages, such as differences compared to humans with respect to physiology and metabolism. For instance, rodents feed mainly as granivore animals in contrast to humans, have faster digestive passage and less fiber digestion, and include fermentation processes in the large caecum. Regarding the gut microbiota, the presence of important genera such as d humans .Compared to humans, the pig presents similarities in anatomical structure and gastrointestinal tract functions, metabolism and diet requirements, and importantly a similar microbiome in the gastrointestinal tract  . FermentIn addition, compared to other animal models, pig models allow for deeper sampling of the gastrointestinal tract and easier induction of diseases under a more controlled diet intake compared to humans. Also, adipocyte size and adipose tissue distribution in pigs are similar to those in humans and the sedentary behavior and fattening of pigs resemble human characteristics . Using aA summary of the in vivo models and their previously mentioned possibilities for the microbiota study is shown in Animal testing is highly useful in analyzing the effect of diet on gut microbes. However, the ethical issues and costs are disadvantages and may restrict their application. An alternative option to this is the use of in vitro intestinal models, which have advantages like reproducible experimentation and standardized conditions. However, these models have limitations in experimental duration, quantity of substrate supply, and a dependence on the inoculation density. In contrast, models using continuous culture systems allow the control of parameters like dilutions, retention time, pH, temperature, substrate replenishment, and toxic waste removal to maintain optimal growth conditions and represent excellent options for use in experimental studies on microbial composition and activity .Regarding continuous in vitro models, the novel Polyfermentor Intestinal Model (PolyFermS) allows for consecutive testing of the impact of different experimental conditions on the same microbiota complex. Poeker et al. used PolyFermS with a first-stage reactor and inocula from two adult proximal colon microbiota and five second-stage reactors to evaluate different conditions and to test the effect of fermentable dietary fibers on the microbiome metabolic functions and composition . They foCulture-based approaches were used during the 1970s at the start of efforts to characterize the human gut microbiota . Howeverm/z), detected by mass TOF analyzers, and finally are compared with database references [Culturomics aims to solve such problems and to fill the gaps in knowledge regarding the human microbiome that are required for researching the microbiota and its relation to human health by growing microorganisms in pure cultures . Culturoferences .Using 16s rRNA gene amplicon sequencing and operational taxonomic unit (OTU) clustering with a high-match cutoff for sequence identity of 97%, the gut microbiota diversity can be described at the species level ,58. HoweMetagenomics, originally used to study complex ecosystems of the environment , is a prWhole-community shotgun sequencing is a metagenomic technique where DNA is obtained from an environmental sample and shotgun-sequenced, and the resulting DNA sequence data are either pieced together using assembly algorithms or analyzed unassembled to monitor whole-community functional capabilities . The priThus, metagenomics is able to determine the abundance of specific functional genes in the corresponding database that can be derived by protein sequences or protein families . From thhttp://www.kegg.jp/) is an encyclopedia of genes and genomes originally developed in 1995 to define nodes of molecular networks. This platform assigns functional meanings to genes and allows for comparisons with high accuracy. The functional information is stored as a KEGG Orthology (KO) related to specific genes and proteins with a functional background. Also, it develops networks of molecular interactions, reactions, and relations as pathway maps and other representations [With respect to the databases, some examples are mentioned. KEGG (ntations .Another database is the Human Microbiome Project (HMP), which was launched in 2008 and is a collection of information about the diversity of the human microbiome in search of patterns associated with physiology and disease. Analysis of the taxonomic and metagenomic composition of the microbiome in a considerable healthy cohort is possible. Recently, the second phase of this project, the Integrative Human Microbiome Project (IHMP) Consortium (2013–2016), which is the search for the relationship between the microbiome in human health and disease in models of pregnancy, inflammatory bowel disease, respiratory viral infection, and the onset of type 2 diabetes, was launched. The database was generated using techniques like mass spectrometry, gene expression, and metagenomics for microbial composition in each disease model .Another of the databases is Mechanism of Action of the Human Microbiome (MAHMI), which is based on the European Union Project on Metagenomics of the Human Intestinal Tract (MetaHIT) established in 2007, whose first objective was to create a repertoire of the microbial genes from the intestinal tract and to thus characterize such microbial consortia. MAHMI comprises information from 300 billion sequences related to peptides produced by the human gut microbiome with cell cycle-regulating and immunomodulatory properties based on in silico protein digestion by proteases and global sequence similarity comparisons with MetaHIT .Dialister sp., Oscillospira sp., and others) was seen. The results supported the hypothesis that a Western diet has a larger impact on gut diversity than does BMI, and “healthy persons” with a normal BMI but with bad dietary habits presented with gut dysbiosis [An example of an application of the database is by Davis et al. in 2017, who performed a cross-sectional case–control study with 81 adult participants (mean = 33 years old) from Alabama, USA, that included participants of both genders with different types of diet and body mass index (BMI), whose stool samples were treated for 16S rRNA gene amplification and high-throughput community sequencing data for diversity analysis. In this work, the Bacteroidetes phylum, considered a healthy-gut bacteria, was most prevalent in overweight or obese persons that consumed westernized diets and also in normal-weight persons who consumed such diets. A high association between processed diets and Firmicutes  high-fat diet (HFD) study using C57BL/6J mice, where a specific group was subjected to only five weeks of HFD, and the last two weeks they were returned to a low-fat diet in an effort to evaluate changes in the gut microbiota and the effect of HFD cessation. The 16S rRNA from stool samples were sequenced and analyzed against Illumina libraries, and the functional analysis of the bacterial DNA was analyzed against the KEGG database using STAMP software. The return of the mice to low-fat diets from week 5 to 7 resulted in normalization of body weight, levels of blood glucose, and levels of hepatic triglycerides to similar levels compared to those in the control group. However, two weeks of HFD cessation was not enough to restore the composition and diversity of the gut microbiota. On the other hand, lipid, starch, and sucrose metabolic properties analyzed using whole bacterial DNA were significantly lower compared to the HFD group, but diversity and composition of the microbiota were only partially restored . The priThe study of the microbiota and its role in the development of obesity and metabolic diseases has opened the possibility of it being considered as a potential treatment for obesity  and seveObesity remains a critical health problem around the world, which makes it imperative to understand its pathology and to search for new treatments. A large amount of research has been done in the field of gut microbiota and its impact on host metabolism, which has become a promising target for new approaches and solutions, but the relationship between the microbiota and obesity remains an intricate question where new information, as well as new questions, emerge day by day. The reductionist perspectives used in past research are no longer sufficient to adequately or precisely explain how the microbiome modulates host metabolism and physiology.Technological advances and new applications have helped in the confrontation of this challenge. However, it is still necessary to develop humanized animal models that more accurately resemble the human species and systems that allow the efficient matching of the interaction of the microbes with the host, not only in a portion of the digestive tract, but in a completely integral context. A deeper characterization of the components of the microbiota is also needed since even recent work related to the subject has focused only on the diversity of species, disregarding aspects of great importance such as the specific strain, the involvement of viruses and other agents, as well as the integration of proteomics and metabolomics to outline a more complete picture that may be solved with efforts to generate multidisciplinary teams and a constant updating of new techniques and methods within the scope of research.Finally, all the knowledge generated by the study of the microbiota opens up possibilities for translational medicine such as fecal transplantation being considered as a possible therapeutic alternative in patients with obesity and metabolic diseases. However, more clinical trials are needed in order to verify the approach as a safe and effective intervention.obesity, metabolic disease, microbiota, microbiome, animal models, microbiota database, and experimental models. From this search, 695 results were obtained, of which 50 were considered to be relevant articles based on their analysis and their inclusion of information directly related to innovative technical approaches or different in vivo models for the study of the relationship between gut microbiota and obesity. After reviewing the information, a second search was performed using the same date range and combination of keywords previously mentioned in combination with new keywords such as metagenomics, culturomics, honeybee, zebra fish, pig, hydra, rat, mice, and germ-free. From this second search, 40 results were considered relevant articles. We excluded articles with repetitive information. Other articles with greater antiquity were included when considered to be classical references. In total, one web page (WHO’s page), two books, 29 reviews, and 51 original articles were cited in this review.Flow of information through the different phases of this review are presented in supplementary


Since 1990 it was proposed that distal and proximal location of colon cancer might follow different biological, epidemiology, pathology and prognosis, probably due to embryologic different development of the two segments of the colon, which may represent two separate disease entities. These differences might have consequences for the treatment of patients with colorectal cancer. To compare the characteristics between patients with right and left colon cancer, with severity and tumor characteristic that influence in the survival of these patients. Were evaluated the outcomes of surgical treatment of patients with colon cancer with data collected retrospectively from prospectively collected database. The tumor’s side did not influence survival time of patients with colon cancer (p=0.112) in the regression model. Only the diseases stage leads to influence on survival time; patients with right colon cancer have more advanced staging (III or IV) and present a risk of death greater in 3.23 times. This analysis provides evidence that the prognosis of localized left-sided colon cancer is better compared to right-sided colon cancer. Also, the patients with right colon cancer have more advanced stage, mucinous tumor and are older. Colorectal cancer (CRC) is the third most common cancer in the USA and the second cause leading to cancer deaths although intense screening programs have declined the incidence rate.,,Since 1990 it was proposed that distal and proximal location of colon cancer might follow different biological, epidemiology, pathology and prognosis,,,Differences have been noted in the following characteristics: right-sided colon cancers are more likely to be exophytic, to be diploid, and to have mucinous histology and high microsatellite instability, whereas left-sided colon cancers are often infiltrating lesions, present with obstructive symptoms, and are more often aneuploidThe objective of this study was to compare the characteristics between patients with right and left colon cancer, with severity and tumor characteristic that influence in the survival of these patients in long-term clinical follow-up.This study was approved by the institutional ethics committee and numbered as 090819.Hospital das Clínicas, School of Medicine of University of São Paulo, SP, Brazil, from 2002 - 2012. Data were collected retrospectively from prospectively collected database. Of 1219 patients treated, a total of 566 patients had colon cancer. Of these, 187 underwent right hemicolectomy and 173 left colectomy with curative intent, thus making the total number of patients included in this study. Patients with incomplete data, synchronous cancers, or with benign disease were previously excluded from the analysis.For the elaboration we evaluated the outcomes of surgical treatment of patients with colon cancer treated in the Service of Colon and Rectal Surgery of the The following factors were studied and compared between the right and left colon cancer: gender, age, tumor location, number of nodes removed in the specimen, lymph node status, T stage and presence of distant metastases. Also these factors were evaluated for the possibility of prognostic impact in 5-year survival.The clinicopathologic and tumor characteristics were studied with the use of summary measures  for quantitative variables and absolute and relative frequencies for qualitative variables.For the overall survival, mean survival times were estimated according to the characteristics of interest using the Kaplan-Meier function. It was not possible to estimate the median time because the number of deaths occurred was less than 50% and compared the overlaps between categories using log-rank tests. The Hazard Ratios (HR) was estimated with the respective 95% confidence intervals using the bivariate Cox regression. For the variables that influenced bivariate in the overall survival, it was verified the joint influence of the same ones in the survival with the use of the Cox multiple regression. Two models were created, one with separate staging in T, N and M and one with final staging of the patient.The characteristics of the patients according to the location of the colon tumor (right and left) were compared using Student’s t or Mann-Whitney tests for the quantitative variables and chi-square tests to verify the existence of association with the qualitative variables.A multiple Cox regression model was created with all patients, controlling the characteristics that presented significance in the survival of the patients of each group and with the variables that differed between the groups to verify if the side of the tumor influences the survival of the patient with colon cancer.The tests were performed with significance level of 5%.Of the 370 patients with colon cancer 187 were right and 171 left sided. Were compared the outcomes of the two groups of patients . Our study shows in the univariable methods that right colon cancer had a significant difference in the age of the diagnosis, more advance stage at the moment of the surgery and more patients with mucinous type of tumor. At the multivariable analysis only advanced stage was more common in right colon cancer patients. Currently, data regarding the prognosis of right-sided vs. left-sided colon cancer are conflicting; however, most studies revealed a poorer survival in right-sided primary tumor location Saltzstein et al.In the present study we only included patients with elective surgery. It has previously been shown that emergency resection is associated with an increased morbidity and postoperative mortality compared with elective resectionWe found a significant difference in the advance stage of patients with right colon cancer, without discrepancies in tumor, lymph node and metastases stage alone. According to Hemminki et al.,,,,,RCC was associated with a larger number of harvested lymph nodes and a larger amount of positive lymph nodes among these than LCC,, In our previous publications we studied the division of the right and left colon cancer2 ,10,36,40. These factors include age, gender, and co-morbidity, which were shown to influence the prognosis, while Benedix et al.Multivariate analyses indicated that other factors than tumour location contribute to the higher mortality in RCC,An important limitation in this paper was the lack of molecular information in this group of patientsThis analysis on colon cancer patient’s provides evidence that the prognosis of localized left-sided colon cancer is better compared to right-sided colon cancer. Also, the patients with right colon cancer have more advanced stage, mucinous tumor and are older.


With more than 500,000 patients with Alzheimer’s disease, constituting nearly 10% of all cases in the US, the state of Florida spends an estimated $20 billion per year on care and treatment related to this disease. The Florida State Plan on Aging reported that 75% of informal caregivers felt that early education and training should be a high priority for the state, and that difficult behaviors and limited knowledge about dementias were among the most significant challenges that they faced. The REACH II intervention is the gold-standard for evidence-based practices that address burden, well-being, and skills training for dementia caregivers. This presentation describes the partnership of a Memory Disorder Clinic (MDC) team and two university-based researchers working to embed a modified REACH protocol into an outpatient clinic. Critical streamlined components and new material designed to innovations since the REACH trials. The FL-REACH protocol is significantly shorter, adds a structured assessment for both patient and family needs, expands to include advanced care planning and grief modules, and intentionally builds linkages to the medical care team, with a focus on outreach to diverse families. This manualized intervention is offered to families of patients diagnosed through the MDC, thus capitalizing on the rapport and trust that is built, and providing in-house opportunities to engage diverse populations with a program grounded in the evidence base. This intervention provides critical foundational training for families that will bridge to seamless team coordination in the future.


Dietary trends and changing lifestyle patterns have been associated with the increasing occurrence of obesity in the Western world. These dietary trends are commonly studied using longitudinal food consumption surveys. An alternative to studying changes in eating behaviour may be found in recipe analysis of traditional cookbooks. Few such studies exist, however, and it is unclear whether dietary trends over time can be identified this way. The present paper analyses full-meal recipes from a traditional Dutch cookbook between 1950 and 2010. The selected recipes show an increase in energy density. Additionally, the protein weight per kcal increased. In general, the observed trends are similar to those identified by the Dutch National Food Consumption Survey. The analysis therefore suggests that traditional cookbooks can be used as an indicator to identify dietary trends over time, although further studies are necessary to support this hypothesis. Similarly, the study of Cohen et al. observes an increase in overall energy intake in the USA, with a percentage-wise decrease of energy from fats, mainly due to an increase in the amount of energy from carbohydrates. In Europe, the overall energy intake and the consumption of meat, fruit, vegetables, nuts and oils increased between 1961 and 2004, while changes in the intake of other food groups differed between Northern, Central and Mediterranean Europe. However, for the specific case of the Netherlands, Hulshof et al. observed a reduction in overall energy intake, while the percentage-wise intake of energy from plant proteins and carbohydrates increased between 1978 and 1997.The increasing occurrence of obesity in the Western world has led to studies analysing the changes in dietary patterns of the population over time. A recent report from the United States Department of Agriculture concludes that there was an increase in food intake from all food groups between 1970 and 2010 found an increase in mean energy content per serving size and an increased average energy density per serving between 1936 and 2006. Similarly, Eidner et al. observed an increased energy content per portion in Danish recipes between 1909 and 2009. Furthermore, an increase was observed within the food group intake of meat, starch products and sauce. The observed trends in both studies are in line with the conclusions on changing dietary patterns mentioned above. This raises the question whether recipes in a Dutch cookbook similarly reflect the observed changes in dietary patterns in the Dutch context.As an alternative to studying changing dietary patterns through nutritional surveys, cookbook recipes could provide an indication of the types and quantities of foods consumed at the time of publishing. However, only a few studies are available in the literature. The (retracted) analysis of a US cookbook by Wansink & PayneIn this brief report we compare recipes from a traditional Dutch cookbook over the period from 1950 to 2010 based on their nutritional content and we discuss the trends observed in this analysis in relation to those found by the Dutch National Food Consumption Survey (DNFCS).. The first edition of this cookbook was published around 1945 (exact date unknown) whereas the latest edition was published in 2010. For this study the edition from 1950 , and those from 1970, 1989 and 2010 were selected(–).The Dutch cookbook ‘Margriet Kookboek’ contains basic recipes for daily usage in a Dutch household. According to the publisher, more than 1·2 million copies were sold over the last decades, giving it a high coverage of the 7·86 million Dutch households counted by the Dutch Central Bureau of Statistics. Although most dinners will contain the three mentioned elements, there are exceptions such as a soup that functions as main course, or a cheese fondue. Recipes that did not describe a main course for dinner, or which according to their description would require additional dishes to form a full meal were excluded from the analysis.Recipes were selected based on their suitability to serve as a full meal according to the standards for a Dutch main course. A typical Dutch dinner consists of a starch source, vegetables and a protein product. In former times, most Dutch dinners contained potatoes, vegetables and meat (if it could be afforded), whereas currently more varied starch and protein sources are used . For items not covered by these lists, the Dutch Food Composition Database (DFCD) and the digital food monitoring application of the Netherlands Nutrition Centre were used. The nutritional content of the selected recipes was calculated based on the DFCD. The form to enter the recipes into a spreadsheet was coded using Visual Basic for Applications and Microsoft Office Excel. An example of the worksheet and the resulting database of recipes are available as Supplementary material.The ingredients of a recipe were classified into several groups , and a standardised form was used to express the more qualitative descriptions (e.g. one onion) in quantitative terms. For this, an internal cookbook weight reference list was usedP value of 0·05 for the significance level. When a significant difference was found, a post hoc analysis was performed with the Mann–Whitney test. For this test, the P value has to be adapted based on the number of pairwise comparisons executed. Comparisons with the Mann–Whitney test were performed for 1950–1970, 1970–1989, 1970–2010 and 1989–2010, with the adjusted P value of 0·0125 for the significance level. All considered recipes from the 1950 edition still existed unchanged in the 1970 edition, which is an edition extended with new recipes. Due to the high similarity of the recipes in the 1950 and the 1970 edition, the pairwise comparisons for 1950–1989 and 1950–2010 were omitted to reduce the number of required Mann–Whitney tests.Data were analysed using the software package SPSS statistics 23 (IBM). Levene statistics showed that data did not have homogeneity of variances. Therefore, comparison between all cookbooks was done with the Kruksal–Wallis test, with a In total, 187 recipes from the four different cookbooks met the selection criteria described in the previous section and were further analysed. The number of recipes selected per cookbook, the average energy content per portion and the portion weight are presented in Regarding meat, by far the most recipes contained pork (eighty-seven out of 187), followed by beef (forty-one out of 187), while thirty-eight recipes did not contain any meat or fish. Looking at animal-based ingredients in more detail, the recipes in the cookbooks of 1950 and 1970 contain ingredients such as lard, while these are not found any more in the recipes from the 1989 and 2010 cookbooks. Additionally, the later cookbooks contain more recipes using easy-to-cook meat, such as chicken. While none of the selected recipes from the 1950 cookbook contained poultry, 25 % of the recipes in the 2010 cookbook did. Later recipes also contained ingredients which were traditionally not used in Dutch cooking, such as olives.The observed overall decrease of portion weight per recipe can be explained by a decrease in the weight of staple foods and vegetables used. The decrease of these generally bulky ingredients also explains the observed reduction in fibre content. Additionally, the decrease of staple foods and vegetables leads to a relative increase of protein ingredients, which are more energy dense. This is also observed by the decreased portion weight per 100 kcal of food. Hence, the reduced portion weight does not lead to a similar reduction of the energy intake per meal.Given the similarities between the cookbooks of the years 1950 and 1970, the observed differences between the years 1970–1989 and 1970–2010 are expected to exist between 1950–1989 and 1950–2010 as well.et al., but contrary to studies from other countries which found an increase in energy intake. At the level of ingredient groups, our results are in line with the DNFCS. However, although a percentage-wise increase in the energy intake of protein was observed, the cookbook analysis suggests this is related to an increased contribution of animal protein, whereas Hulshof et al. observed an increase in plant-based protein. The increased contribution in the newer cookbooks of easy-to-cook animal protein corresponds to the shift in practice away from red meat. The total meat consumption has continued to decline slightly in recent years, which may be reflected by an increased number of non-meat or low-meat recipes in future editions of the cookbook.Our study shows a decrease in energy per recipe over the years, which is in line with the DNFCS report of Hulshof . Carbohydrates make up a large part of the energy consumption in-between meals, which nowadays accounts for about 30 % of the daily energy intake, equalling the carbohydrate consumption at dinner. Hence, the analysis of main meals was not able to detect this trend, showing a limitation of not taking into account the entire diet.A decrease was observed in the contribution of carbohydrates and fibres to the overall energy intake, where the DNFCS shows an increase in the contribution of carbohydrates. Trends in the consumption of these food items are therefore more likely to be spotted in the recipe analysis. Although the Dutch are suggested to be conservative in their eating behaviour, an increasing quantity of food seems to be consumed in-between the typical meals. However, this trend was not significant yet for most of the time period covered in this study.In the Dutch diet, food items such as potatoes, vegetables, legumes, meat, condiments and sauces are predominantly eaten during dinner. Hence, we conclude that this type of traditional cookbooks is likely to follow actual changes in dietary patterns. It may therefore be possible to use the historic developments in traditional recipes as an indicator of the actual changing dietary patterns over time. This is useful for those cases in which there are no detailed data available from food consumption surveys, although more study is required to further support this observation.Despite these limitations, the general trends observed in the cookbook analysis correspond to the trends identified in the DNFCS. Previous recipe analysis studies also observe a similarity between trends identified in recipes and trends identified in food consumption surveysNot all cookbooks will be suitable for such analyses, and the characteristics of suitable cookbooks require further investigation. Additionally, it is not clear how well recipes reflect home cooking practices, as consumers will often deviate from described recipes, or only use them for inspiration. Another limitation to the comparison of recipes throughout time is the possibility of variations in measures, and the interpretation of recipe instructions. The quantities of ingredients lost and wasted, the nutritional content, processing, etc. may differ throughout the years. These variations could affect the results of the analysis.et al., the relationship between recipes in cookbooks and home cooking practices can be investigated. Additional insights can be obtained from a further investigation of meal elements which combine into a meal, of combinations of meals for a daily consumption pattern, and of multi-day menu planning. This would aid the field of diet modelling, and could for instance be used by cookbook publishers to provide an accompanying web application which suggests recipes that improve an overall nutrient score  based on the meals selected by the consumer on the previous days.The results of this cookbook analysis raise the interest in studying other cookbooks and comparing them with results from dietary surveys. An extension of these analyses to the level of micronutrients would also be of interest. Moreover, as suggested by Eidner