MT4-MMP (or MMP-17) belongs to the membrane-type matrix metalloproteinases (MT-MMPs), a distinct subset of the MMP family that is anchored to the cell surface, in this case by a glycosylphosphatidylinositol (GPI) motif. Its expression in a variety of cancers is well documented. However, the molecular mechanisms by which MT4-MMP contributes to tumor development need further investigation. In this review, we aim to summarize the contribution of MT4-MMP in tumorigenesis, focusing on the molecular mechanisms triggered by the enzyme in tumor cell migration, invasiveness, and proliferation, in the tumor vasculature and microenvironment, as well as during metastasis. In particular, we highlight the putative substrates processed and signaling cascades activated by MT4-MMP that may underlie these malignancy processes and compare this with what is known about its role during embryonic development. Finally, MT4-MMP is a relevant biomarker of malignancy that can be used for monitoring cancer progression in patients as well as a potential target for future therapeutic drug development. Matrix metalloproteinases (MMPs) are a family of zinc-dependent endopeptidases that are able to degrade and remodel the extracellular matrix (ECM) by the cleavage of distinct matrix components and also to lead to the proteolytic activation/inactivation of receptors, growth factors, adhesion molecules, cytokines, and other pericellular proteins ,2. Inclu2+ ion binding motif which is essential for the proteolytic activity of the proteinase. This is linked by the hinge region to the hemopexin domain involved in substrate recognition and degradation. Next, MT4-MMP displays a small region called the stem region which has two cysteines. These residues appear to be involved in the dimerization and oligomerization of MT4-MMP . I. I22]. ICompartmentationAs a GPI-anchored protein, MT4-MMP is located on lipid domains that seem to be relevant for its activity . In lineThe functional cooperation between MT4-MMP and other GPI proteins such as the urokinase receptor uPAR may be possible since both colocalize in the same microdomains . AlthougInternalization and recyclingEndocytosis is the mechanism that controls the amount of MT4-MMP anchored to the cell surface through the CLIC/GEEC pathway as well as recycles it back to the cell membrane ,44. The DimerizationA relationship between MT-MMP dimerization and greater proteolytic activity in tumor cells is feasible ,47. MT4-SheddingShedding is another alternative mechanism used by MT-MMPs to control their pericellular proteolytic activity once they are anchored to the cell membrane ,49. ThisInteractionsEGFR has been reported to associate with MT4-MMP by co-immunoprecipitation. Both EGFR and MT4-MMP have been shown to cooperate in tumor cell invasion and signaling, driving cancer cell growth through the regulation of cell cycle proteins such as CDK4 activation and retinoblastoma protein inactivation B 24]. M. M24]. MStudies on mouse embryonic development have shed light on the role of the MT4-MMP gene in the physiological EMT process, in which epithelial cells lose polarity and acquire motility during brain development and heart morphogenesis ,26,51. EMT4-MMP activity is regulated within spatiotemporal frames in normal tissue, likely to maintain normal physiological function. However, its overexpression in breast cancer cells led to enhanced lung metastasis and tumor vessel destabilization in xenografts ,21. In lSeveral proteinases can control the bioavailability and activity of growth factors and regulate cell proliferation. Mechanistically, MMPs release active molecules from the ECM, shed cell surface receptors, and process growth factor binding proteins through their proteolytic activity, which leads to angiogenesis and tumor growth ,56,57. FOne of the most important aspects of tumor cell resistance and recurrence is the microenvironmental changes that occur during tumorigenesis . This inGiven that MT-MMPs can release growth factors sequestered in ECM or cell surface-associated growth factors, they can shape tumor blood vessels in the tumor microenvironment ,62. One A permissive host microenvironment during cancer progression is necessary not only for endothelial cells but also for the distinct immune cell types. In this sense, Host et al. demonstrated that MT4-MMP functions as a key intrinsic tumor cell determinant that contributes to the elaboration of a permissive microenvironment for metastatic dissemination . MT4-MMPDuring the inflammatory process, cytokine production by immune cells is associated with cancer in multiple ways, although information on the contribution of MT4-MMP to the tumor immune response is very limited . MT4-MMPMT4-MMP is also expressed in tumor-associated macrophages (TAMs) . In periMT4-MMP has also been shown to regulate the crawling and recruitment of a subset of circulating monocytes, patrolling monocytes, to inflamed endothelial sites by cleaving the αMβ2 integrin adhesion receptor . While tOne of the critical steps in human cancer progression is the malignant conversion and the acquisition of invasive phenotype. A study conducted to determine factors of epithelial breast invasiveness has shown that MT4-MMP is expressed during the transition from preinvasive to invasive state . Cancer The implication of MT4-MMP in cancer progression is related to its capacity to regulate intrinsic tumor cell proliferation and tumor blood vessel destabilization phenomenon. These two roles can potentiate its tumor and metastatic effects, making it an excellent target. Future studies aiming at targeting these two functions will further define their relevance in cancer and diseases. Nevertheless, the pro-proliferative effect of MT4-MMP on breast cancer cells in vitro has been inhibited by erlotinib, and the presence of MT4-MMP in tumors was shown to be associated with more sensitivity to chemotherapy . FurtherTaken together, these data emphasize the relevance of MT4-MMP in the context of cancer. Although there are many ways by which MT4-MMP participates in tumor progression, the mechanisms used by this proteinase for epithelial–mesenchymal transition and vessel stability in tumors seem to recapitulate those described during embryonic development. However, further investigations are essential to improve our knowledge about the function of MT4-MMP in the embryo as well as in physiological and pathological conditions including cancer progression. In this regard, we want to bring particular attention to the protein expression of MT4-MMP in malignancy. The need for further investigation by bioinformatics and the use of human cancers from selected patients before and after therapy, and the association with clinicopathological features can be useful for deciphering its roles in human cancers. This will help us to develop new therapeutic approaches and to improve the design of new selective MT4-MMP inhibitors to achieve faster diagnosis and more personalized treatment for cancer patients and for vascular diseases.


Experimental and clinical studies have revealed that vascular endothelial growth factor (VEGF) is the predominant angiogenic factor in breast cancer. VEGF expression correlates with inferior outcomes and advanced-stage breast cancer. Bevacizumab is a humanized anti-VEGF monoclonal antibody and has been shown to improve response rates in the treatment of breast cancer, but has failed to improve progression-free survival or overall survival. Anti-VEGF treatment can temporarily normalize tumor vascularization and it is hypothesized that there might be a window of opportunity for chemotherapy. Dynamic contrast-enhanced MRI (DCE-MRI) is the most accurate radiological tool to aid in staging and treatment monitoring of advanced breast cancer. In this work, we showed that DCE-MRI is a sensitive tool to measure the treatment effect of bevacizumab and that it shuts down the vascularization early and abruptly. DCE-MRI may be a suitable tool to find an eventual therapeutic window, and possibly identify a subgroup that would benefit the most from anti-VEGF treatment.Anti-VEGF  treatment improves response rates, but not progression-free or overall survival in advanced breast cancer. It has been suggested that subgroups of patients may benefit from this treatment; however, the effects of adding anti-VEGF treatment to a standard chemotherapy regimen in breast cancer patients are not well studied. Understanding the effects of the anti-vascular treatment on tumor vasculature may provide a selection of patients that can benefit. The aim of this study was to study the vascular effect of bevacizumab using clinical dynamic contrast-enhanced MRI (DCE-MRI). A total of 70 women were randomized to receive either chemotherapy alone or chemotherapy with bevacizumab for 25 weeks. DCE-MRI was performed at baseline and at 12 and 25 weeks, and in addition 25 of 70 patients agreed to participate in an early MRI after one week. Voxel-wise pharmacokinetic analysis was performed using semi-quantitative methods and the extended Tofts model. Vascular architecture was assessed by calculating the fractal dimension of the contrast-enhanced images. Changes during treatment were compared with baseline and between the treatment groups. There was no significant difference in tumor volume at any point; however, DCE-MRI parameters revealed differences in vascular function and vessel architecture. Adding bevacizumab to chemotherapy led to a pronounced reduction in vascular DCE-MRI parameters, indicating decreased vascularity. At 12 and 25 weeks, the difference between the treatment groups is severely reduced. Vascular endothelial growth factor (VEGF) is a predominant angiogenic factor in breast cancer. VEGF expression correlates with advanced-stage breast cancer and inferior outcomes . The AmeEven though many clinical breast cancer studies point to some increase in progression-free survival, none could show statistically significant improvement in overall survival for patients treated with VEGF suppressors . The effThe effect on vascular function and architecture, and the resulting effect on blood, oxygen, and drug distribution of adding bevacizumab to standard chemotherapy is uncertain, but based on its mechanism of action, aiming at disrupting the angiogenic process, it was originally anticipated that it would reduce blood perfusion by shutting down the vasculature. Contrary hypotheses have been proposed, however, suggesting that the disruption of the angiogenic process results in increased blood perfusion through a normalization of the vasculature, making it more efficient ,9.Non-invasive in vivo dynamic contrast-enhanced magnetic resonance imaging (MRI) is a routine clinical tool for longitudinal assessment of changes in tumor vascularization. Semi-quantitative measures or pharmacokinetic modeling of the exchange of contrast agent between the vasculature and the extravascular-extracellular space can provide information on the functionality of the tumor vasculature, whereas texture analysis, in particular the fractal geometry of the image texture of the DCE-MRI images, can provide information on the tumor vascular architecture .The aim of this study was to investigate the effects of anti-angiogenic treatment on tumor vascular functionality and vascular architecture as assessed by DCE-MRI. We compared longitudinal DCE-MRI data between patients receiving chemotherapy or chemotherapy + bevacizumab.The study cohort consisted of 70 patients with large (≥2.5 cm) HER2-negative breast tumors . Patient2, cyclophosphamide 600 mg/m2, and epirubicin 100 mg/m2) every three weeks, followed by either four cycles of 100 mg/m2 docetaxel every three weeks, or 12 weekly infusions of paclitaxel at a dose of 80 mg/m2. Thirty-eight randomly selected patients were given additional intravenous administration of the VEGF inhibitor bevacizumab at a dose of 10 mg/kg every other week, or 15 mg/kg every third week in patients receiving paclitaxel or docetaxel, respectively.Patients received neoadjuvant chemotherapy consisting of four cycles of FEC100 (5 flourouracil 600 mg/mn = 70), after 1 week (n = 26), after 12 weeks (n = 67), and after 25 weeks of treatment (n = 65). Surgery was performed within two weeks after the last MRI exam. The MR exams were performed using a 1.5 T MR scanner  and an 8-channel breast coil . The MRI protocol was designed in accordance with the EUSOBI recommendations [MRI examinations were performed at four different timepoints: before treatment . Next, a third experienced radiologist (SHBB) adjusted the automatically segmented tumor volumes using all sequences from the multiparametric examination . The radTumor volume (V) was obtained by multiplying the number of pixels within the volume of interest (VOI) with the pixel spacing and the slice thickness. Motion correction was applied in patients showing bulk motion during the DCE imaging, using commercially available software . B1-inhoThe semi-quantitative analysis consisted of calculation of time-to-peak  and the area under the contrast curve (AUC) during the first 90 s of contrast enhancement for all voxels within the tumor.The quantitative analysis was performed using the extended Tofts model (ETM) ,18. The A population AIF was created by sampling the signal from the left ventricle on B1-normalized pretreatment image series from 20 patients selected randomly from both treatment cohorts. Using a population AIF rather than an individually sampled AIF has been shown to increase reproducibility in cases where the SNR is limited, or where minor artifacts resulting from B1-normalization can hamper robust AIF sampling in individual patients . The extTumor vasculature has a more chaotic structure than normal vasculature. Baish and Jain introduced a framework for using fractal analysis to measure the complexity of the vascular architecture and demonstrated that the fractal dimensionality of tumor vessel growth patterns is higher than in normal vessels .Michallek et al. found that the vascular tortuosity was strongly correlated to image texture, specifically to the local fractal dimension of the post-injection subtraction images in contrast-enhanced MRI of prostate cancer patients . Buildinp-values are calculated using a two-sided Mann–Whitney test. The statistical significance level is defined as p < 0.05.The main metrics analyzed are the relative, or percentage change in the median value of the respective parameters for each tumor. The change, at any time point, is measured relative to the pre-treatment value. Unless otherwise specified, statistical To minimize data loss, pairwise deletion was used for handling missing values between different analyses. Assuming that the missing data are relatively randomly distributed between cases, the risk of data bias is low.Because the tumors undergo significant volume reduction during treatment, distributions are shown as probability densities rather than frequency histograms. A probability density plot reflects the frequency at which a value appears in the sample and is thus similar to a histogram normalized to the sample size. 3 (1.8–113.7 cm3) and there was no difference between the two treatment groups (p = 0.19). There was no difference in tumor volume or tumor volume change between the two treatment groups at any of the four timepoints  without any further reduction during the next 24 weeks. The reduction in Similar to ribution  and in tribution . For theNone of the patient groups showed a significant change in Examples of fractal dimension maps for two of the patients are shown in p = 0.89). Treatment led to changes in image texture over time for individual patients (p = 0.04) that returned to pretreatment levels within 12 weeks. This was not observed in the chemotherapy + bevacizumab group. In both groups, there was a large increase in the spread in the fractal dimension at 12 weeks, which increased further at 25 weeks. However, the mean values were not significantly different between the two groups and between these two time points. These mean/values were also not significantly different from baseline. There were no differences in mean fractal dimensions at baseline in the two treatment groups  that any additional volume reduction resulting from adding bevacizumab would be difficult to detect.Our study has several limitations. Only one-third of the patients were examined at one week, thus we have significantly lower statistical power at this early time point. We have not evaluated the mechanism of bevacizumab alone but only in combination with chemotherapy. Without a reference tissue, the hypothesis of vascular normalization is difficult to confirm; however, representative breast tissue is impracticable to define. A further limitation is that the interpretation of the pharmacokinetic models is challenging. Our 13 s temporal resolution of the DCE-MRI is higher than the standard clinical routine, but not optimal for the extended Tofts model. Accurate perfusion parameter estimates are also influenced by the sampling of the AIF. A reproducible AIF is difficult to obtain in the breast because the main feeding arteries are small. Thus, the AIF must be sampled from within the heart. An AIF from the heart is subject to dispersion or delay that occurs as the contract agent travels through the tissue from the ventricle to the breast . IdeallyMethodologically, the study was conducted according to the recommendations for appropriate methodology for clinical trials for the assessment of anti-angiogenic and anti-vascular therapeutics using MRI ,15. FurtIn this clinical study of 70 locally advanced breast cancer patients, adding bevacizumab to standard chemotherapy led to rapid changes in DCE-MRI parameters at one week, reflecting vascular shutdown. At one week, the fractal dimension of the chemotherapy-only group was significantly higher. At 12 and 25 weeks, there were no differences between the two treatment groups.


No significant difference was found between the control PMMA group and either 3D-printed material when relined with PMMA . (4) Conclusion: The tested 3D-printed resins achieved a clinically acceptable bond strength when relined with PMMA.(1) Purpose: The aim of the present study was to compare the bond strength between two 3D-printed resins designed for long-term provisional crowns and three different reline materials. (2) Materials and Methods: Rectangular specimens were prepared from two 3D-printed resins (Envision Tech and NextDent C&B) and a conventional self-cure PMMA. Transparent tubes filled with three different reline materials including composite resin, Bis-acryl, and PMMA were bonded to the 3D-printed specimens . Tubes filled with PMMA were bonded to the prepared PMMA specimens which served as the control group . The specimens were subjected to a shear bond strength (SBS) test, and mode of failure was recorded using light microscopy. Statistical analysis was performed using a one-way ANOVA and post hoc Tukey’s tests . (3) Results: The highest SBS value was achieved to both 3D-printed materials with the PMMA reline material. The bond to both 3D-printed materials was lower with Bis-acrylic or composite resin relines in comparison to that with PMMA ( Introduction of the computer-aided design/computer-aided manufacturing (CAD/CAM) technology has revolutionized the manufacturing methods in the field of dentistry and has allowed for the development of a wide range of dental materials to be used as either a temporary or final prosthesis. Traditionally, CAM technologies were subtractive and milled the prosthesis from a pre-made blank. However, the introduction of additive manufacturing (AM), commonly referred to as 3D-printing technology, into the field of dentistry has modified the conventional techniques used in fabrication of dental prostheses. Commonly used 3D-printing technologies in dentistry are stereolithography (SLA) and digital light processing (DLP), both of which utilize a vat filled with photopolymerizable resin. The resin is cured layer by layer by the light source, and then the printed structure undergoes a series of post-processing steps in order to become fully cured . VariousProvisional crowns  are commonly used in dental practices to serve the patient between the tooth preparation and the delivery of the definitive prosthesis in order to prevent tooth migration, further tooth loss due to function, food impaction, tooth sensitivity, gingival overgrowth, and provide acceptable esthetics. In addition to tooth-based restorations, an implant-supported prosthesis would require an appropriate provisional restoration; fabrication of an appropriate interim implant-supported prosthesis would be crucial for a proper gingival tissue contour. Since provisional restorations would be subjected to chewing forces and would be visible, an appropriate and clinically acceptable provisional restoration needs to meet the criteria for mechanical and esthetic properties. These properties would be more critical in patients with parafunctional habits, long-span fixed prostheses, full mouth oral rehabilitations in need of changes in the vertical dimension of occlusion, and patients in need of temporomandibular joint dysfunction therapies. Moreover, due to the fact that provisional restorations may be in contact with gingival and periodontal tissues, it is essential that these materials be biocompatible and provide an acceptable tissue response ,5. In clinical situations such as full-mouth rehabilitations and full-arch implant-supported immediate loading, provisional restorations may stay in function for several months prior to replacement with the definitive prostheses. Hence, provisional materials are needed to maintain their properties over time in the oral cavity. It should also be noted that in these long-term provisional restorations, the restoration needs to be capable of being repaired on the external surface or be relined on the intaglio surface . Both reVarious materials are being used to fabricate provisional restorations. In general, the provisional materials can be classified into two broad categories of resin-based composites and polymer-based materials based on their chemical composition ,7. An exThe most commonly used polymer-based provisional material is polymethylmethacrylate (PMMA), which is the preferred material for long-span and long-term provisional restorations due to its mechanical properties, ease of repair, color stability, and low cost . HoweverThe introduction of 3D-printing technology has had a significant impact on the field of restorative dentistry . Three-dThe aim of the present study was to measure and compare the shear bond strength of two commercially available 3D-printing resins (EnvisionTec and NextDent) approved for long-term provisionals. The primary hypothesis was that the bond strength between the 3D-printed resins and PMMA reline material would be significantly higher than the shear bond strength to bis-acryl and composite reline materials. The secondary hypothesis was that the bond strength to either type of 3D-printed resin would be similar regardless of the type of reline material. In this study, specimens were made from two commercially available 3D-printed resins designed for long-term provisionals, including E-Dent 400 C&B MFH  and NextDent C&B MFH . Both 3D resins are classified as class IIa by the FDA . The conSpecimen geometry in the form of a square was digitally designed in CAD software  and then exported as a Standard Tessellation Language (STL) file format. The STL files were then placed in a 3D printer’s CAM software (Envision One RP 1.20.4470). The objects were placed in horizontal orientation, and supports were created to be able to print the samples. For each type of 3D-printed resin, 33 squares of 12 × 12 mm in dimensions and thickness of 2 mm were printed in a D4K Pro Dental 3D printer . Post-processing followed the manufacturer’s recommendation and included rinsing the 3D-printed samples with isopropanol in an ultrasonic bath and completing the polymerization using a light polymerization chamber . In addition, eleven extra squares were printed and embedded inside poly-vinyl siloxane in order to create a matrix for fabrication of samples from self-cure PMMA  with similar dimensions. For these samples, the liquid and powder were mixed according to the manufacturer’s recommended proportions and were poured into the polyvinyl siloxane matrix and allowed to self-cure according to the manufacturer’s recommended setting time. Hence, a total of 77 base squares were fabricated for this study. Following the fabrication of the samples, each sample underwent a series of polishing in order to standardize the surface roughness, which included 60 grit SiC paper as the first step, followed by 120 grit paper, 320 grit paper, 600 grit paper, and finally 1200 grit SiC paper. The SiC papers were all mounted on a grinding machine , and the polishing was performed using a speed of 200 rpm for 15 s and under running water to remove the debris and keep the papers clean. After polishing, each sample was placed in deionized water and placed in an ultrasonic bath in order to remove the remnants of the silicon carbide sandpapers. The samples were then left to dry at room temperature prior to the bonding procedure. Each 3D-printed resin was divided into three groups according to the type of reline material, resulting in six groups in addition to the control group (n = 11 per group): Group EP used the E-Dent resin specimen as the base and was relined with PMMA (Alike); Group EB used the E-Dent resin specimen as the base and was relined with bis-acrylic ; Group EC used the E-Dent resin specimen as the base and was relined with composite resin ; Group NP used the NexDent resin specimen as the base and was relined with PMMA; Group NB used the NextDent resin specimen as the base and was relined with bis-acrylic; Group NC used the NextDent resin specimen as the base and was relined with composite resin; Group PP served as the control group and used the PMMA specimen as the base and was relined with PMMA. Prior to placement of reline material on the base, in groups EP and NP, the surface was wetted with a PMMA monomer (Alike). In EC and NC groups, ScotchBond Universal adhesive (3M ESPE) was applied to the surface for 20 s and air thinned. 2, Ivoclar Vivadent, Schaan, Liechtenstein). The specimens were then allowed to complete the polymerization process for 24 h in the incubator at 37 °C (24). The tygon tubes were left on the base and were removed right before the shear bond strength test. In order to place a cylinder of the reline material on top of each specimen base, a transparent tygon tube with an internal diameter of 2 mm and height of 3 mm was used. While placed on the base specimen, each tube was filled with the intended reline material . The reline material was light-cured in groups EC and NC for 40 s with a dental light-cure unit . Then, the specimens were examined under an optical microscope  to determine the mode of failure. The mode of failure was categorized into adhesive, cohesive , and mixed. The specimens were attached to a shear-testing jig designed for a universal testing machine and then subjected to shear forces  using a flat blade with crosshead speed of 1 mm/min until failure. The bond strength values (MPa) were calculated by dividing the load (N) at failure by the cylinder’s surface area (mmA representative specimen from each type of failure mode was selected to obtain a scanning electron microscopy (SEM) image. The selected specimens were mounted on a holder and coated using an ion sputter coater. Then, the selected samples were placed in a Hitachi S-2700 scanning electron microscopy machine , and high-resolution images were obtained under 100× magnification.Shear bond strength (MPa) was calculated for each group and is presented as the mean and standard deviation. The data were analyzed using one-way ANOVA and post hoc Tukey’s tests with the significance level set at 0.05 and using SPSS version 26.0 software .p < 0.001). Post hoc tests revealed that the differences between the PP and EB, EC, NB, or NC were statistically significant, and no significant difference was found between EP and PP (p = 0.597) or between NP and PP (p = 0.406). Since the highest SBS was obtained using PMMA as the reline material in all groups, the SBSs of PMMA reline material to different base materials including E-Dent (EP), NextDent (NP), and PMMA (PP) were compared separately, and no significant differences were found (p > 0.05) The shear bond strength (SBS) values of the tested samples are summarized in The mode of failure of the tested groups is summarized in In this study, shear bond strength between two FDA-cleared 3D-printed provisional resins and three different reline materials was tested. The first hypothesis was that the highest bond strength would be found in 3D-printed resins with PMMA as the reline material when compared with bis-acryl and composite reline materials. The second hypothesis was that there will be no differences between the two commercial 3D resins regardless of the type of reline materials. Considering the results of the present study, both hypotheses were accepted, as the highest shear bond strength was observed when the 3D-printed temporary resin was attached to the self-cure PMMA; in addition, both tested 3D-printed resins revealed similar bond strength values when attached to the self-cure PMMA. Since the chemical composition of the 3D-printed resins is not fully clear and there is no clear guideline on how to reline the provisional crowns fabricated with these resins, in the present study, various materials were used to test the SBS to two types of 3D-printed resins. It was found that PMMA resulted in the highest SBS value regardless of the type of base. Chen et al.  found thIt has been shown that surface treatment has the potential to improve the bond strength to provisional materials, although it will add steps, chairside time, and possibly cost to the reline process. Goncalves et al.  showed tFabrication of provisional shells prior to tooth preparation has many advantages, including reduced chairside time, digitally assisted design, less unfavorable odor caused by PMMA, and possibly a reduction in trauma to the tissue from the exothermic reaction  ,26. In aIn the present study, the 3D-printed samples underwent a similar post-curing technique, following the manufacturer’s recommendation, in order to standardize the samples; however, it has been shown that post-curing processes can have a significant effect on the mechanical properties and degree of the conversion of the 3D-printed temporary resins. Mayer et al.  printed a) of the tested composite resins. They observed that Ra values ranged between 0.41 and 0.91 when the samples were polished with 320 grit size sandpaper, between 0.21 and 0.29 with 800 grit size sandpaper, between 0.08 and 0.20 with 1200 grit size sandpaper, and between 0.03 and 0.05 with 2400 grit size sandpaper. They also found that surface roughness affected the shear bond strength values. In the present study, in order to eliminate the effect of surface roughness on shear bond strength values, all tested samples were polished with the same grit size SiC sandpaper.The roughness of the surface has been shown to affect the bond strength of the samples; Kallio et al.  found thThe curing of resins on the surface is partially inhibited by the free radical scavengers, including oxygen in the air, generating the so-called oxygen inhibition layer. This layer consists primarily of unreacted monomers and has lower mechanical properties than deeper layers do. Although one might assume that since this layer contains uncured monomers, it would have higher bond strength. Some have shown that the presence of the oxygen inhibition layer does not affect the shear bond strength . In the 2, and bond strength micro tests have a bonded surface area of less than 3 mm2. Considering the shear bond strength value, micro-tests usually result in higher values when compared with those in shear bond strength macro-tests [An ideal method to test bond strength between two materials needs to be accurate, reliable, have low technique sensitivity, and be unsophisticated and relatively inexpensive. The most common static bond strength tests are shear, tensile, and push out. Shear bond strength and tensile bond strength tests can be further divided into macro- and micro-tests according to the bonding surface area; macro-tests are defined by a surface area larger than 3 mmro-tests . Due to ro-tests . Similarro-tests  used a sOne of the limitations of the present study was the relatively small sample size, and further studies with larger sample sizes would be recommended. In addition, in the present study, only two types of 3D-printed resins were tested. Moreover, the present study design did not consider the intraoral environment, including the chewing forces and constant exposure to saliva and oral cavity temperature. These conditions can possibly affect bond strength and need to be addressed in future studies in order to obtain more clinically relevant information on the reline capability of the 3D-printable resins. Hence, future studies with aging mechanisms, including thermocycling or prolonged storage of the specimens, would be highly recommended in order to evaluate the long-term shear bond strength values to 3D-printed temporary resins. It should also be noted that manufacturers are constantly developing new 3D-printable materials and 3D-printing technology is evolving quickly, and possibly at the time of this publication, new resins and/or new technologies may have become available.Three-dimensional-printed resins for provisional crowns and bridges appear to have a reline strength similar to that of conventional self-cure PMMA provisional material using self-cure PMMA as the reline material.The second highest shear bond strength was obtained by bonding composite resins to the tested 3D-printed resins.Relining the tested 3D-printed resins with bis-acrylic resulted in the lowest shear bond strength value.Both tested 3D-printed resins resulted in similar bond strength regardless of the reline material, suggesting similarities in chemical composition and bonding properties of these resins.Considering the present findings, the need to maintain provisional restorations in the long term in some cases, and the need to modify or characterize the restorations over time, using a self-cure PMMA to reline or add to 3D-printed temporary restorations would be recommended.The present study measured and compared the shear bond strength of different reline materials to two available 3D-printing resins approved for long-term provisional restorations. Considering the findings and limitations of this study, the following conclusions may be drawn:


From January 2020 to December 2022, China implemented “First-level-response”, “Normalized-control” and “Dynamic-COVID-zero” to block the COVID-19 epidemic; however, the immediate and long-term impact of three strategies on other infectious diseases and the difference in their impact is currently unknown. We aim to provide a more comprehensive understanding of the impact of non-pharmacological interventions (NPIs) on infectious diseases in China.We collected data on the monthly case count of infectious diseases in China from January 2015 to July 2022. After considering long-term trends using the Cox-Stuart test, we performed the two ratio Z tests to preliminary analyze the impact of three strategies on infectious diseases. Next, we used a multistage interrupted-time-series analysis fitted by the Poisson regression to evaluate and compare the immediate and long-term impact of three strategies on infectious diseases in China.Compared to before COVID-19, the incidence of almost all infectious diseases decreased immediately at stages 1, 2, and 3; meanwhile, the slope in the incidence of many infectious diseases also decreased at the three stages. However, the slope in the incidence of all sexually transmitted diseases increased at stage 1, the slope in the incidence of all gastrointestinal infectious diseases increased at stage 2, and the slope in the incidence of some diseases such as pertussis, influenza, and brucellosis increased at stage 3. The immediate and long-term limiting effects of “Normalized-control” on respiratory-transmitted diseases were weaker than “First-level-response” and the long-term limiting effects of “Dynamic-COVID-zero” on pertussis, influenza, and hydatid disease were weaker than “Normalized-control”.Three COVID-19 control strategies in China have immediate and long-term limiting effects on many infectious diseases, but there are differences in their limiting effects. Evidence from this study shows that pertussis, influenza, brucellosis, and hydatid disease began to recover at stage 3, and relaxation of NPIs may lead to the resurgence of respiratory-transmitted diseases and vector-borne diseases.The online version contains supplementary material available at 10.1186/s12889-023-16318-y. Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and poses a serious threat to people’s health . After tNPIs in China during the COVID-19 pandemic have impacted the incidence of many diseases –13. HoweInterrupted time series analysis (ITSA) is a very powerful quasi-experimental design that controls for the effect of the trends before intervention on the time series, thereby allowing us to obtain more robust and reliable results . ITSA cahttp://www.nhc.gov.cn/jkj/s2907/new_list.shtml). The population data in China were obtained from the World Bank (https://data.worldbank.org.cn/indicator/SP.POP.TOTL?locations=CN). All data used in this study were publicly available aggregate data and did not include human individuals.Data on the monthly cases of infectious diseases in China from January 2015 to July 2022 were obtained from the infectious disease bulletin of the Chinese National Health Commission , vector-borne diseases , gastrointestinal infectious diseases , sexually transmitted diseases , and infectious diseases with other transmission routes .We used the Cox-Stuart test to evaluate the long-term trends of infectious diseases from January 2015 to December 2019. Because if the trends of infectious diseases after the interventions (three COVID-19 control strategies) were consistent with their long-term trends before the intervention, then we could not determine whether the intervention had an effect on infectious diseases because the trends after the intervention could be a continuation of their long-term trends before the intervention and not related to the intervention. Conversely, if the trends after the intervention were inconsistent with their long-term trends before the intervention, we then believed that the change in the trends may be caused by the intervention. Furthermore, if the trends after the intervention were consistent with the long-term trends before the intervention, we can next compare the monthly case counts after the intervention with their predicted case counts. If their difference was statistically significant, we also believed that this difference was caused by the intervention. In this study, the predicted case counts were obtained using a seasonal autoregressive integrated moving average (SARIMA) model based on the monthly case counts from January 2015 to December 2019.Subsequently, we calculated the growth rate of the monthly case counts and used the two ratio Z tests to compare the monthly case counts of infectious diseases at different stages. First, we compared the monthly case counts of infectious diseases at each stage with that in the same period before COVID-19. Moreover, we also compared the monthly case counts of infectious diseases at each stage with that in the same period at the other two stages, respectively. We aimed to evaluate the impact of three strategies on infectious diseases and the differences in their impact. The calculation formula for the growth rate was:β) obtained from the Poisson regression and took it as effect estimate. Detailed information, parameter explanations, and IRR calculation formula of the ITSA can be found in Supplementary Material.After the above comparison, we used the monthly case counts from January 2017 to July 2022 to conduct the ITSA for infectious diseases affected by COVID-19 control strategies. The data points used in the ITSA were sufficient and we also adjusted the seasonality using Fourier terms to improve the linear trend of the time series, so this study met the applicable criteria of ITSA [Noteworthy, the number of data points may affect the robustness of the time series analysis results, so we again used the same method to re-construct the ITSA for sensitivity analysis based on the monthly case counts of infectious diseases from January 2015 to July 2022. After sensitivity analysis, the robustness of results was considered excellent if the IRRs for the majority of parameters did not show significant differences and the main findings did not change.P < 0.05.The Cox-Stuart test, two ratio Z tests, and SARIMA model were performed using R software , ITSA and figure production was performed using Stata software . All testing was two-sided with significance determined at predict=271, growth rate = − 63.10%, P < 0.05) and malaria  were lower than the predicted case counts. Compared to May 2018 to July 2019, the monthly case counts of most infectious diseases remained lower but the monthly case counts of brucellosis were higher at stage 2. Compared to August 2018 to July 2019, the monthly case counts of almost all infectious diseases were lower but the monthly case counts of pertussis, influenza, and brucellosis were higher at stage 3.Compared to January to April 2019, the monthly case counts of almost all infectious diseases at stage 1 were lower but the trends of measles and malaria were consistent with the long-term trends , gastrointestinal infectious diseases (HFMD and infectious diarrhea), and sexually transmitted diseases (syphilis and gonorrhea) were higher at stages 2 and 3, see Table Compared with the pre-COVID-19 period, the incidence of all respiratory-transmitted diseases decreased immediately and only the slope in the tuberculosis incidence increased at stage 1, see Fig. Compared with the pre-COVID-19 period, the incidence of most vector-borne diseases decreased immediately but the slope in the incidence of some vector-borne diseases increased at stage 1, see Figs. Compared with the pre-COVID-19 period, the incidence of all gastrointestinal infectious diseases, sexually transmitted diseases, and infectious diseases with other transmission routes decreased immediately but the slope of all sexually transmitted diseases increased at stage 1, see Figs. After entering stage 2, the incidence of many gastrointestinal infectious diseases, all sexually transmitted diseases, and all infectious diseases with other transmission routes decreased immediately and the slope of many sexually transmitted diseases also decreased compared with the pre-COVID-19 period; the incidence of many gastrointestinal infectious diseases increased immediately and the slope of all sexually transmitted diseases decreased compared with stage 1. “Normalized-control” still had immediate limiting effects on gastrointestinal infectious diseases, sexually transmitted diseases, and infectious diseases with other transmission routes, but were weaker than “First-level-response”. Meanwhile, “Normalized-control” had stronger long-term limiting effects on sexually transmitted diseases.After entering stage 3, the incidence of all gastrointestinal infectious diseases, sexually transmitted diseases, and infectious diseases with other transmission routes decreased immediately and the slope of many gastrointestinal infectious diseases also decreased compared with the pre-COVID-19 period. Similarly, the incidence of many gastrointestinal infectious diseases, sexually transmitted diseases, and infectious diseases with other transmission routes decreased immediately and the slope of many gastrointestinal infectious diseases also decreased compared with stage 2. “Dynamic-COVID-zero” still had immediate limiting effects on gastrointestinal infectious diseases, sexually transmitted diseases, and infectious diseases with other transmission routes, and were stronger than “Normalized-control”. Meanwhile, “Dynamic-COVID-zero” had stronger long-term limiting effects on gastrointestinal infectious diseases than “Normalized-control”.We used January 2015 to January 2020 as the pre-COVID-19 period and then fitted the ITSA for sensitivity analysis. Tables COVID-19 poses a significant threat to the life and health of the population worldwide, and effective and rigorous strategies for COVID-19 control are critical to block the COVID-19 epidemic , 22. Stu“First-level-response” reduced immediately the incidence of almost all respiratory-transmitted diseases, and the trends in their incidence at stage 1 were also decreasing, which may be related to the following reasons. Firstly, mainland China required residents to live and work at home and closed schools and entertainment venues as well as banned large gatherings at stage 1, so the movement and concentration of the population were immediately and severely restricted at this stage , 27. TheUsing the pre-COVID-19 period as a reference, the incidence of almost all respiratory-transmitted diseases also decreased immediately at stage 2. This is because although the stringency of NPIs has declined and social activities are gradually returning to normal, people’s mask wear remained high and the number of travel activities and the size of gatherings were limited at this stage, so these measures remained effective in reducing the incidence of respiratory-transmitted infections. However, compared with stage 1, the incidence of many respiratory-transmitted diseases increased immediately at stage 2, and their trends also increased at this stage. Which may be related to the decline in the strictness of COVID-19 control measures.At stage 3, the incidence of most respiratory-transmitted diseases was lower but the trends and incidence of pertussis and influenza were increasing. Although the stringency of NPIs declined at stage 3, it was still higher than that during the pre-COVID-19 period, so “Dynamic-COVID-zero” still has a little limiting effect on respiratory-transmitted diseases. Moreover, the motivation of people to actively seek medical care gradually increased with the decreasing stringency of NPIs at stage 3, so the number of patients that developed tuberculosis and other infectious diseases at stage 2 was delayed and accumulated to be diagnosed at stage 3 was very little, which also caused the incidence of some infectious diseases at stage 3 was lower. However, it should be noted that the limiting effects of “Dynamic-COVID-zero” on respiratory-transmitted diseases  may be weaker than the first two strategies. We believed that the possible causes of this phenomenon are the stringency of NPIs, the geographic regions affected by NPIs, and the number of people affected by NPIs at this stage were lower than at the previous two stages , 8. We iCompared with the pre-COVID-19 period, three COVID-19 control strategies can effectively reduce the incidence of many vector-borne diseases  in the short term. This is because bats have been considered as the host of COVID-19 at the early stage, which has led to increased vigilance of people against wildlife and reduced the risk of contracting vector-borne diseases from contact with wildlife , 35. MorThree COVID-19 control strategies can reduce immediately the incidence of most gastrointestinal infectious diseases, sexually transmitted diseases, and infectious diseases with other transmission routes. This is because the closure of restaurants, increased environmental disinfection, restricted close contact, and personal cleaning can affect the spread of gastrointestinal infectious diseases , 41. In Our study classifies infectious diseases by transmission routes and also takes into account the long-term trends and seasonality of infectious diseases, providing a comprehensive evaluation of the impact of three strategies on infectious diseases in China. However, there are some limitations. First, our study used summary data on infectious diseases, so we could not understand the impact of three COVID-19 control strategies on infectious diseases in different regions and different age groups. Moreover, the decrease in the number of reported cases of some infectious diseases may be caused by a decrease in surveillance sensitivity during the COVID-19 epidemic, which does not imply a decrease in the true number of infectious disease cases. Next, this study is a non-experimental study that describes more of a correlation than a causal relationship between the prevention and control measures of COVID-19 and the incidence of infectious diseases. Finally, this study does not include potential influences such as meteorological factors in the ITSA.Below is the link to the electronic supplementary material.Supplementary Material 1Supplementary Material 2Supplementary Material 3Supplementary Material 4


Is there a difference in the long-term risk of mortality and morbidity outcomes for adults with hypertension starting 1 of 3 antihypertensive treatments: thiazide-type diuretic, calcium channel blocker, or angiotensin-converting enzyme (ACE) inhibitor?In this prespecified secondary analysis of outcomes of 32 804 participants in a randomized clinical trial and posttrial up to 23 years later, there was no significant difference in mortality due to cardiovascular disease among the 3 antihypertensive treatment groups. However, there was an increased risk of stroke outcomes for ACE inhibitors compared with diuretics; after accounting for multiple comparisons, this increased risk was no longer significant.Long-term follow-up supports the main findings that the diuretic group had similar cardiovascular outcomes and the ACE inhibitor group had higher stroke mortality risk. The long-term relative risk of antihypertensive treatments with regard to mortality and morbidity is not well understood.To determine the long-term posttrial risk of primary and secondary outcomes among trial participants who were randomized to either a thiazide-type diuretic, calcium channel blocker (CCB), or angiotensin-converting enzyme (ACE) inhibitor with up to 23 years of follow-up.This prespecified secondary analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), a multicenter randomized, double-blind, active-controlled clinical trial, followed up with participants aged 55 years or older with a diagnosis of hypertension and at least 1 other coronary heart disease risk factor for up to 23 years, from February 23, 1994, to December 31, 2017. Trial participants were linked with administrative databases for posttrial mortality (N = 32 804) and morbidity outcomes (n = 22 754). Statistical analysis was performed from January 2022 to October 2023.Participants were randomly assigned to receive a thiazide-type diuretic (n = 15 002), a CCB (n = 8898), or an ACE inhibitor (n = 8904) for planned in-trial follow-up of approximately 4 to 8 years and posttrial passive follow-up for up to 23 years.The primary end point was mortality due to cardiovascular disease (CVD). Secondary outcomes included all-cause mortality, combined fatal and nonfatal (morbidity) CVD, and both mortality and morbidity for coronary heart disease, stroke, heart failure, end-stage renal disease, and cancer.A total of 32 804 participants  were followed up for all-cause mortality and a subgroup of 22 754 participants  were followed up for fatal or nonfatal CVD through 2017 . Cardiovascular disease mortality rates per 100 persons were 23.7, 21.6, and 23.8 in the diuretic, CCB, and ACE inhibitor groups, respectively, at 23 years after randomization . The long-term risks of most secondary outcomes were similar among the 3 groups. Compared with the diuretic group, the ACE inhibitor group had a 19% increased risk of stroke mortality  and an 11% increased risk of combined fatal and nonfatal hospitalized stroke .In this secondary analysis of a randomized clinical trial in an adult population with hypertension and coronary heart disease risk factors, CVD mortality was similar between all 3 groups. ACE inhibitors increased the risk of stroke outcomes by 11% compared with diuretics, and this effect persisted well beyond the trial period.NCT00000542ClinicalTrials.gov Identifier:  This prespecified secondary analysis of a randomized clinical trial assesses the long-term posttrial risk of morbidity and mortality outcomes among participants who were randomized to a thiazide-type diuretic, calcium channel blocker, or ACE inhibitor with up to 23 years of follow-up. Participants in the other 3 groups were followed up for a mean (SD) of 4.9 (1.3) years during the trial, with 6-year primary outcome rates per 100 persons ranging from 11.3 to 11.5.2 No significant differences were detected among the 3 treatment groups for the primary outcome and all-cause mortality.3 Compared with the chlorthalidone group, the amlodipine group had a higher rate of heart failure (HF), and the lisinopril group had higher rates of cardiovascular disease (CVD), stroke, and HF.The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) was a multicenter, randomized, double-blind, active-controlled clinical trial comparing initial antihypertensive treatment with a calcium channel blocker (amlodipine), an angiotensin-converting enzyme inhibitor (lisinopril), or an α-blocker (doxazosin), all compared with a thiazide-type diuretic  for the composite outcome of fatal coronary heart disease (CHD) or nonfatal myocardial infarction (MI).4 During the posttrial period, no significant differences were detected among the 3 treatment groups for the primary outcome. Compared with chlorthalidone, the risk of HF was higher for the amlodipine group, and the risk of stroke mortality was higher for the lisinopril group (particularly for Black participants).A previous study reported mortality and morbidity outcomes of ALLHAT participants during 8 to 13 years after randomization using in-trial data plus posttrial data from administrative databases to assess the long-term effects of first-step antihypertensive treatment.We linked the data to obtain an additional 11 years of passive administrative data since the last report, for a total of 19 to 24 years of follow-up after randomization. We aimed to determine whether the aforementioned legacy effects  persisted after the trial and whether the increase in the incidence of events resulting from longer follow-up led to sufficient power to detect differences among the randomization groups.5 Posttrial follow-up data were gathered from the National Death Index (NDI), Social Security Administration, and Center for Medicare & Medicaid Services (CMS) databases from the earliest available date through 2017. Participants in the trial provided written informed consent before study onset, and each of the 623 participating North American study centers obtained institutional review board approval for the trial. The institutional review board of The University of Texas Health Science Center at Houston likewise approved the long-term follow-up study  reporting guideline.This prespecified secondary analysis of the ALLHAT, a multicenter, randomized, double-blind, active-controlled clinical trial, followed up with participants for up to 23 years, from February 23, 1994, to December 31, 2017. The methods and primary results of the ALLHAT and posttrial outcome results through 2006 have previously been published.2 Participants were randomized to 4 treatment groups using a 1.7:1 ratio: chlorthalidone (n = 15 255), lisinopril (n = 9054), amlodipine (n = 9048), or doxazosin (n = 9061). At the beginning of the trial, participants engaged in a titration protocol of their randomized (step 1) medication group aimed at achieving a target blood pressure under 140/90 mm Hg. Participants were offered open-label step 2 and step 3 medications if their blood pressure could not be controlled at the maximum allowed daily dose of the step 1 drug. After completion of the initial titration phase, routine participant visits were scheduled for once every 3 months through the first year of the trial and once every 4 months from that point forward. Because of the limited in-trial follow-up due to early stopping, the doxazosin group was excluded from this extended posttrial follow-up (9061 participants excluded).Participants aged 55 years or older who received a diagnosis of hypertension and had a documented history of CVD, atherosclerotic CVD (ASCVD), and/or another risk factor for CHD were eligible for the ALLHAT.International Statistical Classification of Diseases and Related Health Problems coding were described in previous reports of posttrial mortality and morbidity and were demonstrated to be highly reliable.4 In brief, the causes of death were coded according to the International Classification of Diseases, Ninth Revision (ICD-9) for those occurring prior to 1999 and the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision for those occurring in and after the year 1999 via the World Health Organization’s translation tool.6Canadian participants (n = 553) were excluded from long-term follow-up because a lack of identifying information precluded the acquisition of comprehensive mortality records for the posttrial period, leaving 32 804 in the current study’s analytic sample . Deaths that occurred during the in-trial period were ascertained and classified by investigators and confirmed by medical records, including death certificates. If the cause of death was unknown to an investigator, a death certificate was obtained from the NDI. Posttrial mortality data, including date and cause of death, were obtained from the NDI Plus service, as was information for unknown causes of in-trial deaths. Details of the categorization of the causes of death and the handling of The primary end point of this long-term follow-up study was mortality due to CVD, which was defined as death due to MI, stroke, or HF. Key secondary outcomes included all-cause mortality, mortality due to CHD, stroke mortality, HF mortality, and mortality due to end-stage renal disease (ESRD). Additional mortality outcomes included death due to the following causes: other CVD falling outside the predefined category, cancer of any type, and other non-CVD causes.ICD-9 codes originating from the source.Nonfatal events were defined by hospitalization due to a prespecified cause. Except for ESRD, the availability of nonfatal outcome data was limited to participant medical records originating from US clinical centers unaffiliated with Veterans Affairs (VA) that were linked to valid Medicare or Social Security numbers. Therefore, participant medical records originating from VA sources (n = 5558) and non-Medicare participants (n = 4492) were excluded from long-term morbidity follow-up. Events that occurred during the in-trial period were ascertained and classified by investigators and confirmed by discharge summaries. Information on ESRD events  that occurred during the in-trial period was gathered from the United States Renal Data System (USRDS) database through 2006. Data on posttrial morbidity outcomes were gathered from the CMS and USRDS databases. Classification of events identified through CMS data was accomplished using The following morbidity outcomes were prespecified as secondary end points: fatal or nonfatal CVD , fatal or nonfatal CHD , fatal or nonfatal stroke , fatal or nonfatal HF , and fatal or nonfatal ESRD . Cancer mortality and morbidity  were included as additional outcomes of interest.Multivariable analyses were adjusted for relevant baseline demographic and clinical data, including dichotomized categories of 65 years of age or older, sex, self-identified Black race, self-identified Hispanic ethnicity, educational attainment, prior receipt of antihypertensive drug therapy, aspirin use, estimated glomerular filtration rate, high-density lipoprotein cholesterol level, past or current cigarette use, type 2 diabetes status, history of CHD, history of ASCVD, history of other ASCVD , history of MI or stroke, history of coronary artery bypass graft, major ST segment depression detected on electrocardiogram, left ventricular hypertrophy , obesity , systolic and diastolic blood pressure, and participation in the Lipid Lowering Trial. Because outcome data were evaluated from the time of randomization to the date of the last follow-up, it was not possible to make use of covariate measurements gathered during the in-trial period, extension period, or via external data sources  after the date of randomization.2 test of independence for dichotomous and categorical variables and 1-way analysis of variance for continuous variables. The cumulative incidence of mortality and morbidity outcomes was calculated from the date of randomization  to the date of last follow-up . For the evaluation of mortality outcomes, all participants whose date of death according to NDI records fell after the date of randomization were considered part of the population at risk. The population at risk for analyses of morbidity outcomes comprised members of the population at risk for the mortality cohort who had not experienced a nonfatal event of interest up to the date of randomization. The Kaplan-Meier method was used to calculate the 10-year and 23-year cumulative incidence rates of mortality and morbidity outcomes per 100 persons. Effect estimates of assigned treatments for the primary and secondary outcomes over the course of the full follow-up period were calculated using Cox proportional hazards regression and reported as hazard ratios (HRs) with 95% CIs. Multivariable Cox proportional hazards regression analyses adjusting for baseline covariates were also performed for the primary and secondary outcomes. The proportionality assumption was evaluated by the Schoenfeld residuals test and through visual inspection of the log-log Kaplan-Meier curves to ensure no intersection. To assess the heterogeneity of treatment effects by covariates , interactions were tested using an unadjusted Cox proportional hazards regression model of each mortality and morbidity outcome separately for each covariate. As an alternative method for variable selection for the multivariable models, we applied the least absolute shrinkage and selection operator (LASSO) penalty to multivariable Cox proportional hazards regression models, using 10-fold cross-validation procedures to estimate the optimal lambda (tuning parameter). Selected variables were then used in supplementary multivariable Cox proportional hazards regression models. To test whether treatment effects differed during vs after the trial, we tested interactions between the randomization groups and a time-dependent indicator of whether the event occurred after the trial. To help guide the interpretation of the many analyses, we also applied the Holm multiple test procedure for the main effects separately for each randomization group pairwise comparison.7 All analyses were conducted using R, version 4.0.2 . All P values were from 2-sided tests and results were deemed statistically significant at P < .05.Statistical analysis was performed from January 2022 to October 2023. Differences in demographic and clinical characteristics among the randomized study groups at trial baseline were assessed using the χThe mortality cohort comprised 32 804 participants  A. Baseli2, ST segment depression, left ventricular hypertrophy, history of MI or stroke, history of CHD, aspirin use, and baseline blood pressures .Cumulative incidence rates of mortality and morbidity outcomes by treatment group are shown in ressures . Lisinopressures , but thiressures . The Kapressures . Stroke ressures C. Combinressures . After aAlhough the candidate covariates for some models differed when LASSO-penalized regression methods were applied as a variable selection procedure, the resulting AHRs were nearly identical to those that were produced from the full multivariable model, and the 95% CIs were of comparable width (eTables 5-7 in P = .02 for interaction) and CHD mortality  than those in the chlorthalidone group . Among men, those in the lisinopril group had a higher risk of fatal or nonfatal CVD than those in the chlorthalidone group .Subgroup analyses by age, sex, race and ethnicity, and type 2 diabetes status demonstrated consistent results with overall analyses for most outcomes, including CVD mortality , the results for lisinopril vs chlorthalidone for stroke and stroke mortality are almost the same.This analysis has some important limitations similar to the last follow-up report. First, participants may have stopped the randomization drug once they were unblinded. The unblinding also may have lead to biases. Second, we were not able to conduct a passive outcome ascertainment for all ALLHAT participants due to data availability , resulting in a reduced sample size. Therefore, the individuals in the morbidity and mortality cohorts may not be representative of the general population. However, there were no noted significant differences in the measured baseline demographic distribution for this cohort compared with the full study. Third, posttrial antihypertensive medication use is unknown between study completion (2002) and 2006, and crossover or regression to more similar medications is possible, which could dilute the original treatment distinctions among the 3 randomization groups. A previous study examined posttrial antihypertensive medications based on Medicare Part D–linked data from 2007 and found significant mixing of antihypertensive classes.In this prespecified secondary analysis of a randomized clinical trial using Medicare billing data to obtain follow-up for up to 23 years after baseline, we found similar results as those found during the ALLHAT. Angiotensin-converting enzyme inhibitors were associated with an increased risk of stroke outcomes  compared with diuretics, and this effect persisted well beyond the trial period.


BackgroundDeep inspiration breath-hold (DIBH) has been established as a standard technique to reduce cardiac dose. The part of the heart exposed to radiation can be significantly decreased using the DIBH technique during tangential left-sided breast cancer (LSBC) irradiation.AimThe objective of this study was to investigate the intra-fraction breath-hold stability and inter-fraction consistency of patient breath-hold against the threshold as a function of air volumes in the setting of active breathing coordinator (ABC)-based DIBH (ABC-DIBH) treatment to LSBC.MethodsA total of 34 patients treated with external beam radiation therapy (EBRT) to the left breast using the ABC-DIBH device were included. The frequency of breath-holds per fraction and the entire course of treatment along with the total treatment time was evaluated for all patients. A prescription dose of either 200 cGy  or 267 cGy (hypofractionation) was administered during 649 fractions, resulting in a total of 4,601 breath-hold measurements being evaluated. The amplitude of deviation in terms of air volumes between the baseline threshold and the patient-specific measurement (during each breath-hold) per fraction was used to define the DIBH stability. Likewise, the consistency of the breathing amplitudes was used to define the compliance of patient breath-holds throughout the entire treatment period. Positional accuracy was evaluated using orthogonal  images.ResultsThe average number of breath-holds measured over the entire course of treatment for each patient was 144 inspirations (58-351). Similarly, the average number of breath-holds for each fraction during the course of treatment was 11 inspirations (7-21), which included setup imaging and treatment. The total number of breath-holds reduced significantly  with hypofractionation  as compared to conventional fractionation . The average breath-hold threshold in terms of air volume was 1.41 L (0.6-2.1 L) for all patients. The total treatment time reduced significantly after the third fraction . The average deviation between the measured and baseline threshold breath-holds during the course of treatment was 0.5 L/sec (0.12-1.32 L/sec). The consistency of the breathing amplitudes were maintained within ±0.05 L during the entire treatment for all patients. The average translational shifts measured during setup were 0.28 cm ± 0.3 cm, 0.38 cm ± 0.4 cm, and 0.21 cm ± 0.3 cm in the lateral, longitudinal, and vertical directions, respectively.ConclusionThe study has demonstrated the variations in intra-fraction breath-hold stability and inter-fraction breath-hold consistency in terms of air volumes for patients who were treated for LSBC. The frequency of breath-holds was observed to be higher with increased total treatment time for the first few fractions and reduced over the course of treatment. Breast cancer is the most prevalent cancer and the leading cause of mortality among women worldwide. One in four women is diagnosed with breast cancer according to the International Agency for Research on Cancer (IARC) . Breast Radiation therapy (RT) after breast-conserving surgery in the early stages of breast cancer is the current treatment of care, as RT has proven to improve local control of the tumor and increase overall survival . Most poInvoluntary organ movements, such as respiratory motion during RT between and within fractions, may cause dose delivery errors due to excess normal tissue being irradiated and missing target volume . AdverseStrategies currently used to reduce the effects of respiratory motion include integration of respiratory motion into the treatment plan, forced shallow breathing by abdominal compression, deep inspiration breath-holding (DIBH), respiratory gating techniques, and four-dimensional computed tomography (4D CT). Traditionally, DIBH techniques are used, which function by separating the heart from the field of irradiation. DIBH works by inflating the lungs and displacing the heart caudally, which can be used to achieve a lower radiation dose to normal intrathoracic tissues. The DIBH technique enables the reduction of doses to vital organs while maintaining the recommended dose for the tumor ,11. SeveDIBH reduces the overlap of the heart and lungs with the treatment fields by taking advantage of restricted organ motion during the respiratory cycle . When coHowever, DIBH techniques require patient compliance and longer imaging and treatment duration . ThroughThe respiration and breath-hold patterns of patients differ during and between fractions. As treatment techniques become more sophisticated through the use of advanced motion management systems, there are uncertainties in the equipment that may impair overall treatment quality. The total geometric uncertainties, especially when more equipment is employed, necessitate investigation during the course of treatment. Currently, RT treatment plans for breast cancer are created using two opposing non-divergent isocentric tangent fields along with beam modifiers to homogenize the dose within the target ,12. For The objective of this study was to evaluate intra-fraction stability and inter-fraction consistency of patient breath-holds as a function of air volumes and flow in the setting of ABC-DIBH-based treatment for LSBC. The set-up uncertainty was evaluated using portal images.Patient stratificationIn this retrospective study, 34 consecutive patients diagnosed with LSBC who received RT treatment between September 2022 and May 2023 using the ABC-DIBH technique, ABC device , following breast-conserving therapy or mastectomy, were included. The median age is 46 years old (±10).Simulation using the ABC-DIBH deviceThe ABC system uses a spirometer, which consists of a balloon valve, turbine impeller, and optoelectronic sensor to gauge patients' respiratory volumes. The patient's airflow is stopped by the balloon valve at a predetermined breath-hold volume. For a known air volume, the turbine impeller makes one revolution. The opto-electronic sensor tracks rotations and picks up airflow signals.A GE Discovery CT590 RT CT scanner  was used for the simulation using institutional imaging protocols. The patients were simulated in a supine position on a breast board with arms abducted and externally rotated for DIBH using a slice thickness of 5 mm and covered from the mandible to the thorax, encompassing all normal structures. The DIBH technique was used in patients who were able to hold their breath for 20-30 seconds, at least three times, and was performed using an ABC device . Patients received coaching until they could consistently perform DIBH. Subsequently, a breath-hold was used to obtain a CT image in order to enhance the gap between the heart, chest wall, and breast tissue by taking advantage of lung hyperinflation.The target and OAR contouring were delineated by a consultant oncologist based on the Radiation Therapy Oncology Group (RTOG) guidelines to define the clinical target volume (CTV) and planning target volume (PTV), which included the entire contralateral chest wall and lymph node region around the collar bone. The OARs included the ipsilateral lung, contralateral lung, contralateral breast, heart, and spinal cord ,23.RT treatment planningTreatment plans were generated using the CMS Monaco  treatment planning system (TPS), which utilizes the collapsed cone algorithm. All cases were planned using the three-dimensional conformal therapy (3D CRT) technique. For each patient, the PTV and various OARs were considered. The goal of the treatment plan was to have 95% of the PTV covered by at least 90% of the prescribed dose. OAR dose limits were optimized to be as low as possible according to the quantitative analysis of normal tissue effects (QUANTEC) guidelines and RTOG protocols -25. EithImage guidance and treatment deliveryElekta Infinity®  with an Agility MLC® head was used to deliver all plans. The beam modulator head assembly consisted of 80 leaf pairs for a total of 160 leaves, which were projected at an isocenter width of 5 mm. For all plans, an MV setup image was acquired and registered with digitally reconstructed radiographs to verify the patient setup. The chest wall was used as the landmark for the breast, lung, and heart, whereas the clavicle was utilized as the landmark for lymph nodes. The treatment couch corrections in our institution's DIBH image guidance protocol are based on portal imaging, which includes the acquisition of orthogonal anterior-posterior and lateral MV images at the first three fractions and weekly thereafter. Daily acquisitions were limited to tangential pre-port images (treatment fields) to verify the breath-hold utilizing the distance between the heart and chest wall. For patients with affected lymph nodes, an anterior image is acquired once a week to correct for potential patient rotation. All images were captured while maintaining the pre-set breath-hold setting using the ABC-DIBH device. The delivery of the treatment and ABC device is controlled manually by the radiation therapist. The treatment is paused manually on observing a discrepancy of ±0.05 L in the breath-hold measurement (air volumes) from the threshold level, and the patients would be communicated to re-adjust the breath-hold. Couch corrections were applied if the position errors of the bony structures in the tangential breast images were greater than 4 mm and if the residual errors of the bony landmarks for the lymph node areas were greater than 4 mm and the reference distance between the heart and chest wall deviated by more than 4 mm. To confirm the accuracy of the corrections, more anterior and lateral orthogonal images were obtained at the following two fractions . Data extraction using the ABC-DIBH deviceDuring CT simulation and treatment delivery, including daily imaging for setup, the ABC-DIBH device was used to record the air volume of every patient. In this study, the breath-hold volume that the ABC recorded during the CT scan was referred to as the reference breath-hold volume. Every 20 ms, the output data file records the patient's breathing during imaging and treatment. The actual breath-hold volumes held by the patients during treatment were compared to the reference breath-hold volume and analyzed as a function of the airflow volume.Intra-fraction stability and inter-fraction reproducibilityThe frequency of breath-holds per fraction and the entire course of treatment was evaluated for all patients. The breath-hold deviation between the baseline threshold and the patient-specific measurement in terms of air volumes (during each breath-hold) per fraction was used to define ABC-DIBH intra-fraction stability. Similarly, the measurement of air volumes for the entire treatment period  was evaluated for the patient-specific inter-fraction ABC-DIBH reproducibility. The consistency of the breathing amplitudes was used to define reproducibility between breath-holds in this context. The difference in air volumes between the minimum and maximum values was calculated and used as a measure of reproducibility. This was done by calculating the breathing amplitudes of all the breath-holds performed on a patient ,28.The demographics, prescription doses, clinical characteristics, staging, and dosimetric parameters of the patients assessed in this study are reported in Table Figure A fractional prescription dose of either 200 cGy or 267 cGy was administered during 649 fractions, resulting in a total of 4,601 breath-holds being evaluated. The average frequency of breath-holds over the entire course of treatment for each patient was measured to be 144 inspirations (15-351), as shown in Figure The ABC device recorded the air volumes as a function of airflow rate throughout the entire radiation treatment. During breath-holding, each patient showed a range of airflow rates. As a result, the differences in the airflow rate during breath-holds were what led to the fluctuations in air volume. Figure The present study addresses the intra-fraction stability and inter-fraction reproducibility of patient breath-holds during the delivery of ABC-based RT treatment to left-sided breast tumors. This study reveals that changes in breath-hold volume, as determined by spirometry, have an impact on doses to the heart over the course of RT. At a given point of time during treatment, if the measured breath-hold of a patient is lesser than the reference breath-hold, it will lead to increased dose to the heart. In terms of breathing characteristics, such as airflow rate, breath-hold time, and threshold, the study found that each patient displayed individual differences. Patient-specific breath-hold settings are essential to increase the accuracy of the OAR dose because reproducibility when using breath-hold platforms for RT is still a concern. Variations in air volume were unavoidable since we set the threshold lower, at around 75% of the maximal breath-hold as recommended by the manufacturer, despite the fact that a consistent breath-hold volume is expected throughout the entire treatment using the ABC breath-hold approach.In addition, we hypothesize that proper coaching is essential to create a calm environment for treatment as patients' discomfort can result in rapid breathing or complicated breath-holds. Longer treatment sessions may cause patient discomfort after repeated breath-holds; as a result, appropriate coaching is needed to maintain the stable breath-hold comfortably.The patient compliance to reference breath-hold in terms of air volume increased over the course of treatment. One of the potential explanations was that as the treatment progressed, patients became accustomed to and at ease with the ABC-DIBH. Furthermore, the ability of the patients to maintain a constant lung volume may have increased as a result of improvements in their ability to breathe during the treatment.Xiao et al. examined over 7,200 DIBH cycles using the surface imaging system AlignRT . The median of the 5th to 95th percentile range of translational displacement during a single breath-hold or overall breath-holds throughout the course of a single treatment session was investigated . The curMoreover, DIBH requires patient adherence to actively breathe in a predefined threshold volume before every treatment field delivery. The average time spent on breath-hold practice before CT simulation was reported to be 20 minutes . FurtherLimitationsContinuous portal imaging for position monitoring during treatment delivery has many benefits, but the technique is limited to conformal fields and necessitates the use of X-ray visible markers, such as the chest wall. The analysis of 3D motion is challenging due to the 2D nature of portal images. The DIBH technique used in this study was limited by manual controlling of the ABC device by the radiation therapist during simulation and treatment.The study has demonstrated the variations in intra-fraction breath-hold stability and inter-fraction breath-hold consistency in terms of air volumes for patients who were treated for LSBC using the ABC-DIBH device. The average absolute difference in the amount of airflow measured during the course of treatment was maintained within 0.05 L. The frequency of breath-holds was observed to be higher with the increased total treatment time for the first few fractions and reduced after the fourth fraction.


The pre-operative blood basophil count and pre-operative bEBR were higher in AERD patients than in the control group . The results of this study support the hypothesis that polyps removal may contribute to reducing the inflammation and activation of basophils.Aspirin-exacerbated respiratory disease (AERD) is characterized by eosinophilic asthma, chronic rhinosinusitis with nasal polyps (CRSwNP) and intolerance to cyclooxygenase-1 inhibitors. Interest is emerging in studying the role of circulating inflammatory cells in CRSwNP pathogenesis and its course, as well as their potential use for a patient-tailored approach. By releasing IL-4, basophils play a crucial role in activating the Th2-mediated response. The main aim of this study was to, first, investigate the level of the pre-operative blood basophils’ values, blood basophil/lymphocyte ratio (bBLR) and blood eosinophil-to-basophil ratio (bEBR) as predictors of recurrent polyps after endoscopic sinus surgery (ESS) in AERD patients. The secondary aim was to compare the blood basophil-related variables of the AERD series (study group) with those of a control group of 95 consecutive cases of histologically non-eosinophilic CRSwNP. The AERD group showed a higher recurrence rate than the control group ( Aspirin-exacerbated respiratory disease (AERD) is an inflammatory condition that consists of eosinophilic asthma, chronic rhinosinusitis with nasal polyps (CRSwNP) and respiratory reactions to cyclooxygenase-1 (COX-1) inhibitors. The reported prevalence of AERD in CRSwNP patients ranges between 8.7% and 26% ,4,5. ComA standard histological examination can identify the main inflammatory cells (such as eosinophils and neutrophils) that have been associated with CRSwNP relapse ,10,11,12In 2004, Hartnell et al.  investigIt is unknown which biomarkers effectively predict the recurrence of nasal polyposis in patients with AERD undergoing endoscopic sinus surgery (ESS). The main aim of this study was to, first, investigate the level of blood basophils, bBLR and bEBR as predictors of recurrent polyps after the ESS in AERD patients. The secondary aim was to compare the blood basophil-related variables of the AERD series (study group) with those of a control group of 95 consecutive cases of histologically non-eosinophilic CRSwNP.This retrospective study was conducted in accordance with the principles of the Helsinki Declaration. All patients signed a detailed informed consent form and gave their written permission for clinical case publication. The data were examined in agreement with the Italian privacy and sensitive data laws, as well as the internal regulations of Padova University’s Otolaryngology Section. Furthermore, all enrolled patients signed a form in which they consented “to the use of their clinical data for scientific research purposes in the medical, biomedical and epidemiological fields, also in order to be recalled in the future for follow-up needs”.A consecutive series of 39 adult patients who had undergone surgery for CRSwNP with AERD at the Otolaryngology Section of Padova University between 2009 and 2022 was retrospectively assessed. In contrast, the control group consisted of another consecutive series of 95 CRS cases with a histological diagnosis of non-eosinophilic polyposis who had undergone surgery by the same surgical team in the same period. Patients were excluded from the study in the event of a lack of pre-operatory blood basophils data, a diagnosis of systemic inflammatory disease or autoimmune disease, or acute or chronic infectious conditions other than sinusitis; cancer; blood disorders; a history of systemic corticosteroid use; or chronic kidney disease. Patients whose CRSwNP had already recurred before their blood was sampled post-operatively were also excluded, as their recurrent disease might have influenced their post-ESS eosinophil, basophil and lymphocyte counts.Information about sensitivity to acetylsalicylic acid or other non-steroidal anti-inflammatory drugs (NSAIDs) was obtained from their medical history recorded in Padova University Hospital’s electronic archives . Preoperative blood cell counts and percentages were obtained for each patient. The necessary laboratory tests were performed at least three months after withdrawing oral steroids and one month after withdrawing nasal steroids; they were all processed at the same laboratory  and certified in compliance with ISO standard 15,189. The total and specific IgE for Dermatophagoides pteronyssinus and Dermatophagoides farinae, birch pollen, pellitory, grass mix, cat and dog dander, Alternaria alternata, Aspergillus fumigatus and common ragweed were determined. A diagnosis of asthma was confirmed according to the definition of the Global Initiative on Asthma . The recAfter the ESS, surgical tissue was stained with hematoxylin and eosin to measure the eosinophil count, examining 5 high-power fields (HPFs) (400×) selected from each sample and recording the average number of eosinophils. The eosinophilic histotype corresponded to a mean score of ≥10 eosinophils/HPF . PatientAll patients were treated post-operatively with isotonic saline solution irrigations twice a day (20 mL per irrigation), nasal steroids (fluticasone furoate 110 μg daily (55 μg per nostril) or mometasone furoate 200 μg daily (100 μg per nostril)). Adequate therapy was prescribed for asthmatic and allergic patients. Follow-ups with rigid 0° or 30° endoscopes were scheduled 3, 6 and 12 months after the ESS, and yearly thereafter.9/L), blood basophils percentage, bBLR and bEBR.From a laboratory viewpoint, for all patients considered in the study, the following pre- and postoperative variables were determined and archived: blood basophils count . The results are reported as the median and range for quantitative variables and as the count and percentage for categorical variables.The recurrence-free interval was measured as the time from the ESS to recurrence or the last follow-up evaluation for censored patients.The prognostic role of each blood basophils-related variable on recurrence-free interval for AERD and control patients was assessed with univariate Cox regression.p-value and hazard ratio (HR) with a 95% confidence interval (CI).The plot of the cumulative Martingale residuals against the values of the covariate and Kolmogorov-type supremum test based on a sample of 1000 simulated residual patterns was used to test the proportionality for quantitative covariates. The results are expressed as the The AERD and control groups were compared with the Mann–Whitney test for quantitative variables after having checked the normality with the Shapiro–Wilk test and the Q–Q plot. The chi-square test was applied for categorical variables.p-value < 0.05 was considered indicative of statistical significance.A A total of 39 patients with AERD  and 95 consecutive control cases with non-eosinophilic CRSwNP  were enrolled in the study.The CRSwNP recurrence rate after ESS was significantly higher in the AERD group than in the control group, with a calculated HR of 5.473 (95% CI 2.753–10.881) .9/L, respectively; p-value 0.0364)  .p-value 0.4931).Interestingly, considering the same variable post-operatively, there was no significant difference between the two groups   .p-value 0.6607).Furthermore, this basophil-related variable was not significantly different between the two cohorts after surgery , leading to an accumulation of eosinophils ,42. New The main weaknesses of this study concern the retrospective design and the limited number of patients, in particular those with available post-operative laboratory data. The main strengths lie in the intra-group homogeneity of the series of patients considered since the (i) histopathological analyses were all done by a dedicated head and neck pathologist; (ii) ESS was performed by the same team of surgeons; (iii) the endoscopic follow-up after surgery was conducted by the same team; (iv) recurrent eCRSwNP was always confirmed endoscopically; and, lastly, (v) all blood tests were performed over a long-term post-operative period at the same laboratory.Before surgery, among subjects with CRSwNP, blood basophil counts and bEBR were significantly higher in patients with AERD than in those without AERD. The retrospective nature of the study did not allow for correlating these data with significant blood increases of any cytokines involved. AERD was associated with a higher risk of recurrence of nasal polyps. Among all the CRSwNP cases, polyps removal with ESS may have helped in reducing inflammation and the activation of basophils and eosinophils. The same result is obtained with biological therapy. Therefore, our observations seemed interesting in relation to the routine use of anti-interleukin biologics. Furthermore, a possible synergistic effect of surgery associated with the biologic therapy should be further investigated.