bluuebunny/crossref_metadata_2025 huggingface dataset:
Online learning during COVID-19 produced equivalent or better student course performance as compared with pre-pandemic: empirical evidence from a school-wide comparative study
Authors: Zheng Meixun , Bender Daniel , Lyon Cindy
Published: September 2021

Background

The COVID-19 pandemic forced dental schools to close their campuses and move didactic instruction online. The abrupt transition to online learning, however, has raised several issues that have not been resolved. While several studies have investigated dental students’ attitude towards online learning during the pandemic, mixed results have been reported. Additionally, little research has been conducted to identify and understand factors, especially pedagogical factors, that impacted students’ acceptance of online learning during campus closure. Furthermore, how online learning during the pandemic impacted students’ learning performance has not been empirically investigated. In March 2020, the dental school studied here moved didactic instruction online in response to government issued stay-at-home orders. This first-of-its-kind comparative study examined students’ perceived effectiveness of online courses during summer quarter 2020, explored pedagogical factors impacting their acceptance of online courses, and empirically evaluated the impact of online learning on students’ course performance, during the pandemic.

Method

The study employed a quasi-experimental design. Participants were 482 pre-doctoral students in a U.S dental school. Students’ perceived effectiveness of online courses during the pandemic was assessed with a survey. Students’ course grades for online courses during summer quarter 2020 were compared with that of a control group who received face-to-face instruction for the same courses before the pandemic in summer quarter 2019.

Results

Survey results revealed that most online courses were well accepted by the students, and 80 % of them wanted to continue with some online instruction post pandemic. Regression analyses revealed that students’ perceived engagement with faculty and classmates predicted their perceived effectiveness of the online course. More notably, Chi Square tests demonstrated that in 16 out of the 17 courses compared, the online cohort during summer quarter 2020 was equally or more likely to get an A course grade than the analogous face-to-face cohort during summer quarter 2019.

Conclusions

This is the first empirical study in dental education to demonstrate that online courses during the pandemic could achieve equivalent or better student course performance than the same pre-pandemic in-person courses. The findings fill in gaps in literature and may inform online learning design moving forward.
Mechanisms involved in the anti-tumor effects of Toosendanin in glioma cells
Authors: Zhang Chaochao , Gao Haijun , Liu Ziqiang , Lai Jiacheng , Zhan Zhixin , Chen Yong , Huang Haiyan
Published: September 2021

Background

Toosendanin (TSN) is a triterpenoid compound mainly used as an ascaris repellant. Recent studies have shown that it possesses antitumor effects in many types of tumor cells. However, the effects of TSN on glioma cells have rarely been reported.

Methods

Different assays were performed to investigate the effects of TSN on the different glioma cell lines including U87MG and LN18. The assays included colony formation, wound healing, and transwell assays. Furthermore, Hoechst 33342 staining, flow cytometry, and western blotting analysis were performed to investigate the apoptotic activities of TSN. Finally, the results were confirmed using a xenograft tumor model that comprised of nude mice.

Results

In vitro, the CCK-8 and colony formation assays showed that TSN effectively inhibited glioma cell proliferation. Moreover, the inhibitory effects on glioma cell migration and invasion were demonstrated through the wound healing and transwell assays, respectively. Hoechst 33342 staining, flow cytometry, and western blotting assays demonstrated the significant effect of TSN in the apoptosis induction of glioma cells. Furthermore, the anti-glioma effect of TSN was exerted through the inhibition of the PI3K/Akt/mTOR signaling pathways as demonstrated by western blotting analysis. In addition, the effects of TSN on glioma cell viability, apoptosis, cell cycle arrest, migration, and invasion were reversed by 740Y-P, a PI3K activator. Finally, the mouse xenograft model confirmed the suppressive effect of TSN on tumor growth in vivo.

Conclusion

Our results suggest that TSN is a promising chemotherapeutic drug for patients with glioma.
Household catastrophic health expenditure and its effective factors: a case of Iran
Authors: Ravangard Ramin , Jalali Faride Sadat , Bayati Mohsen , Palmer Andrew J. , Jafari Abdosaleh , Bastani Peivand
Published: September 2021

Background

The World Health Organization (WHO) has placed special emphasis on protecting households from health care expenditures. Many households face catastrophic health expenditures (CHEs) from a combination of economic poverty and financing the treatment of medical conditions. The present study aimed to measure the percentage of households facing catastrophic CHEs and the factors associated with the occurrence of CHEs in Shiraz, Iran in 2018.

Methods

The present cross-sectional study was performed on 740 randomly selected households from different districts of Shiraz, Iran in 2018 using a multi-stage sampling method. Data were collected using the Persian version of the “WHO Global Health Survey” questionnaire. CHEs were defined as health expenditures exceeding 40% of households’ capacity to pay. Households living below the poverty line before paying for health services were excluded from the study. The associations between the households’ characteristics and facing CHEs were determined using the Chi-Square test as well as multiple logistic regression modeling in SPSS 23.0 at the significance level of 5%.

Results

The results showed that 16.48% of studied households had faced CHEs. The higher odds of facing CHEs were observed in the households living in rented houses (OR = 3.14, P-value < 0.001), households with disabled members (OR = 27.98, P-value < 0.001), households with children under 5 years old (OR = 2.718, P-value = 0.02), and those without supplementary health insurance coverage (OR = 1.87, P-value = 0.01).

Conclusion

CHEs may be reduced by increasing the use of supplementary health insurance coverage by individuals and households, increasing the support of the Social Security and the State Welfare Organizations for households with disabled members, developing programs such as the Integrated Child Care Programs, and setting home rental policies and housing policies for tenants.
Tocilizumab for massive refractory pleural effusion in an adolescent with systemic lupus erythematosus
Authors: De Matteis Arianna , Sacco Emanuela , Celani Camilla , Uva Andrea , Messia Virginia , Nicolai Rebecca , Pardeo Manuela , De Benedetti Fabrizio , Bracaglia Claudia
Published: September 2021

Background

Pleural effusion in systemic lupus erythematous (SLE) is a common symptom, and recent studies demonstrated that IL-6 has a pivotal role in its pathogenesis.

Case presentation

We report a case of a 15 years old Caucasian boy with a history of persistent pleural effusion without lung involvement or fever. Microbiological and neoplastic aetiologies were previously excluded. Based on the presence of pleuritis, malar rash, reduction of C3 and C4 levels and positivity of antinuclear antibody (ANA) and anti-double stranded DNA (dsDNA), the diagnosis of juvenile SLE (JSLE) was performed. Treatment with high dose of intravenous glucocorticoids and mycophenolate mofetil was started with partial improvement of pleural effusion. Based on this and on adults SLE cases with serositis previously reported, therapy with intravenous tocilizumab (800 mg every two weeks) was started with prompt recovery of pleural effusion.

Conclusion

To the best of our knowledge, this is the first case of JSLE pleuritis successfully treated with tocilizumab.
HPV16 E6-specific T cell response and HLA-A alleles are related to the prognosis of patients with cervical cancer
Authors: Cai Hongchao , Feng Yaning , Fan Peiwen , Guo Yuping , Kuerban Gulina , Chang Cheng , Yao Xuan , Peng Yanchun , Wang Ruozheng
Published: September 2021

Background

T cell epitopes are polypeptide fragments presented to T cell receptors by MHC molecules encoded by human leukocyte antigen (HLA) genes after antigen-presenting cell processing, which is the basis for the study of antigen immune mechanism and multi-epitope vaccine. This study investigated T cell response to HPV16 E6 and E7 in patients with cervical squamous cell carcinoma (CSCC). Also, the HLA-A allele distribution was compared among patients and evaluated as a factor to predict prognosis in these patients.

Materials and methods

This study recruited a total of 76 patients with International Federation of Gynaecology and Obstetrics (FIGO) stage IIB–IIIB CSCC. Mononuclear cells were isolated from the peripheral blood before any treatment and then enzyme-linked immunosorbent spot (ELISpot) assay was employed to measure the E6 and E7-specific T cell response. HLA‐A alleles were typed using Sanger sequencing‐based typing techniques with DNA extracted from the peripheral blood. The correlation between the T cell responses, HLA‐A allele distribution and patient prognosis were analysed using the Kaplan–Meier method, univariate and multivariate Cox proportional hazard models.

Results

The frequency of HPV E6-specific T cell responses in patients with pelvic lymph node metastasis was lower than that in patients without metastasis (P = 0.022). The 5-year overall survival (OS) rates of patients were 87.5% for those responding to multiple overlapping peptides, 72.7% for those responding to 1–2 overlapping peptides and 47.7% for non-responders (P = 0.032). Cox regression analysis indicated that the presence of HLA*A02:07 was independently associated with worse OS (hazard ratio [HR] 3.042; 95% confidence interval [CI] 1.348–6.862;P = 0.007), while concurrent chemoradiation therapy (CCRT) was independently associated with better OS (HR 0.475; 95% CI 0.232–0.975;P = 0.042).

Conclusion

The results of our study demonstrated that the level of HPV16 E6-specific T cell response and HLA*A02:07 were correlated with prognosis in patients with advanced CSCC.
Fortification with mushroom flour (Pleurotus ostreatus (Jacq.) P. Kumm) and substitution of wheat flour by cassava flour in bread-making: Nutritional and technical implications in eastern DR Congo
Authors: Irakiza Patrick Ngirabakunzi , Chuma Géant Basimine , Lyoba Tresor Zongwe , Mweze Marcelin Aganze , Mondo Jean Mubalama , Zihalirwa Parent Kulimushi , Mapatano Sylvain , Balezi Alphonse Zihalirwa , Mushagalusa Gustave Nachigera
Published: September 2021

Background

The import of wheat flour is the major driver for the high prices and low use of bakery products in non-producing tropical countries such as the Democratic Republic of Congo (DRC). These products’ high prices worsen the risk of malnutrition and food insecurity among rural and resource-poor populations. This study aimed at substituting the imported wheat flour with less expensive local cassava flour fortified with oyster mushroom flour in order to mitigate the nutritional crisis in the region.

Methodology

Series of experiments were conducted by substituting wheat flour with cassava flour at proportions of 10–25% to find the optimal combination. In addition, oyster mushroom flour (2.5–10%) was added to the composite flour to compensate for nutrient deficiencies of cereals and tuber crops. The overall aim was to identify the optimal wheat–cassava–mushroom combination, improving the nutritional value of breads while keeping their physico-chemical and organoleptic properties.

Results

Results showed that 0–10% mushroom flour increased bread protein from 19.63 to 22.66%. Besides, 7.5% mushroom flour allowed rising the bread calories from 311.8 to 354.5 kcal, and the dry matter from 77.33 to 87.86%. The wheat substitution for cassava fortified with mushroom flour negatively affected the bread volume, color and taste (p < 0.001). However, other organoleptic features remained unchanged. The different breads were microbiologically stable for bacteria, but susceptible to fungal attacks.

Conclusion

This study recommended 5–15–80% and 10–10–80% mushroom–cassava–wheat composite flour for better bakery results, good consistency and high protein and energy contents, for improving the nutritional status of populations in the tropical non-wheat producing regions such as DRC. Efforts are necessary to improve the taste and color of the mushroom-fortified bread to increase its uptake and competitiveness in the local markets.
Perceived weight gain and eating disorder symptoms among LGBTQ+ adults during the COVID-19 pandemic: a convergent mixed-method study
Authors: Tabler Jennifer , Schmitz Rachel M. , Charak Ruby , Dickinson Eliza
Published: September 2021

Background

In this study, we further explore the role of COVID-19 pandemic-related stress, social support, and resilience on self-reported eating disorder symptoms (using the EDE-QS) and perceived weight gain among lesbian, gay, bisexual, transgender, and/or queer (LGBTQ+ adults) in the US context during the COVID-19 pandemic.

Methods

Employing a convergent mixed method design, we surveyed 411 individuals, and conducted qualitative semi-structured follow-up interviews with 43 LGBTQ+ -identifying survey respondents. Using OLS regression and multinomial logistic regression, we modeled eating disorder symptoms and perceived weight gain among LGBTQ+ individuals (n = 120) and cisgender and heterosexual-identifying women (n = 230), to cisgender and heterosexual-identifying men (n = 61). We also explored complementary interview narratives among LGBTQ+ people by employing selective coding strategies.

Results

Study results suggest that LGBTQ+ individuals are likely experiencing uniquely high levels of pandemic-related stress, and secondly, that pandemic-related stress is associated with elevated eating disorder symptoms and higher risk of perceived weight gain. Nearly 1 in 3 participants reported eating disorder symptoms of potentially clinical significance. Social support, but not resilient coping, was found to be protective against increased eating disorder symptoms. Qualitative analyses revealed that LGBTQ+ individuals situated physical exercise constraints, challenging eating patterns, and weight concerns within their pandemic experiences.

Conclusions

Clinicians of diverse specialties should screen for eating disorder symptoms and actively engage patients in conversations about their COVID-19-related weight gain and eating behaviors, particularly with LGBTQ+ -identifying adults.
Translation of the Chinese version of the modified Yale Food Addiction Scale 2.0 and its validation among college students
Authors: Zhang Hui , Tong Tong , Gao Ye , Liang Chunguang , Yu Haitao , Li Sisi , Yan Xiangru , Wang Liying
Published: September 2021

Background

Obesity prevalence has substantially increased in China over the past decade. In China, over 1 in 7 individuals meet the criteria for overall obesity, and 1 in 3 meet the criteria for abdominal obesity, obesity has become a significant problem. Studies have shown that food addiction and obesity are inextricably linked. The modified Yale Food Addiction Scale 2.0 (mYFAS 2.0) is a brief measurement for assessing food addiction. This study aimed to explore the structure of the Chinese version of the mYFAS 2.0 and assess the occurrence of food addiction in a sample of college students in Northeast China.

Methods

A cross-sectional design was conducted in a sample of 1099 undergraduate students in Northeast China. Participants completed the sociodemographic questionnaire, the Chinese version of the mYFAS 2.0, the Barratt Impulsiveness Scale (BIS-8), and the Self-Esteem Scale (SES) to test the hypothesis. Exploratory factor analysis and confirmatory factor analysis were performed to examine the underlying factor structure of the mYFAS 2.0. Two weeks later, 62 students who participated in the first test were recruited to evaluate the test–retest reliability.

Results

The Chinese version of the mYFAS 2.0 demonstrated adequate internal consistency, good test–retest reliability and satisfactory construct validity. The results of the confirmatory factor analysis found that the Chinese version of the mYFAS 2.0 demonstrated a good fit to the two-factor solution identified by the exploratory factor analysis and showed superior fit indices compared to the one-factor model. The prevalence of food addiction in our sample was found to be in line with rates observed in other Asian and Western samples. The mYFAS 2.0 symptom count scores were correlated with BMI, the idea of dieting to lose weight, the desire to overeat, low self-esteem, and impulsivity.

Conclusion

The results indicate that the Chinese version of the mYFAS 2.0 has good reliability and validity, and that it can be considered a tool to evaluate the addictive eating behaviours of undergraduate students.
Investigating drug–target interactions in frontotemporal dementia using a network pharmacology approach
Authors: Balasubramanian Archana , Sudarshan Raksha , Chatterjee Jhinuk
Published: September 2021

Background

Frontotemporal dementia (FTD) is the second most common type of dementia in individuals aged below 65 years with no current cure. Current treatment plan is the administration of multiple medications. This has the issue of causing adverse effects due to unintentional drug–drug interactions. Therefore, there exists an urgent need to propose a novel targeted therapy that can maximize the benefits of FTD-specific drugs while minimizing its associated adverse side effects.

In this study, we implemented the concept of network pharmacology to understand the mechanism underlying FTD and highlight specific drug–gene and drug–drug interactions that can provide an interesting perspective in proposing a targeted therapy against FTD.

Results

We constructed protein–protein, drug–gene and drug–drug interaction networks to identify highly connected nodes and analysed their importance in associated enriched pathways. We also performed a historeceptomics analysis to determine tissue-specific drug interactions.

Through this study, we were able to shed light on the APP gene involved in FTD. The APP gene which was previously known to cause FTD cases in a small percentage is now being extensively studied owing to new reports claiming its participation in neurodegeneration. Our findings strengthen this hypothesis as the APP gene was found to have the highest node degree and betweenness centrality in our protein–protein interaction network and formed an essential hub node between disease susceptibility genes and neuroactive ligand–receptors.

Our findings also support the study of FTD being presented as a case of substance abuse. Our protein–protein interaction network highlights the target genes common to substance abuse (nicotine, morphine and cocaine addiction) and neuroactive ligand–receptor interaction pathways, therefore validating the cognitive impairment caused by substance abuse as a symptom of FTD.

Conclusions

Our study abandons the one-target one-drug approach and uses networks to define the disease mechanism underlying FTD. We were able to highlight important genes and pathways involved in FTD and analyse their relation with existing drugs that can provide an insight into effective medication management.
Implementation of strategic cost management in manufacturing companies: overcoming costs stickiness and increasing corporate sustainability
Authors: Rounaghi Mohammad Mahdi , Jarrar Hajer , Dana Leo-Paul
Published: September 2021

In today's competitive world, three factors: price, quality and time have critical roles in the success of the companies to achieve success in the competition. For this purpose, the companies have to also adapt themselves to changes in technology and environment. Strategic cost management is the best way to improve the sustainable management models in the manufacturing companies. Strategic cost management has solved many of the problems and shortcomings of traditional accounting system and by accurate determination of costs, their proper allocation to products and elimination of waste, tries to create value for shareholders by using continuous improvement. The objective of this paper was to develop a management model called strategic cost management that reduced costs stickiness and increased corporate sustainability. Using strategic cost management approach can create competitive advantage for the companies, because it provides accurate cost price information so that the users can easily understand the information. The aim of the paper by introducing strategic cost management was to contribute toward accurate pricing, which could result in the increased profitability and competitiveness of the manufacturing companies in a highly competitive global market and at a market‐based price. Also, due to the growing competition among companies in providing high quality products with reasonable prices, a precise system of measurement of the cost of the product is necessary.
Clinical Review on the Management of Metastatic Renal Cell Carcinoma
Authors: Tran Jennifer , Ornstein Moshe C.
Published: September 2021

Renal cell carcinomas vary considerably in their tumor biology and disease course, which is reflected in the range of treatment paradigms in localized and metastatic renal cell carcinoma (mRCC). Active surveillance remains an important component of all renal cell carcinoma management. In mRCC, the rapid evolution from cytokine-based therapy to targeted therapy to immunotherapy with checkpoint blockade has revolutionized the field and drastically altered treatment outcomes. More recently, combination therapies have become a standard of care for most patients with mRCC. In this review, we highlight recent critical data that led to changes in treatment paradigms and provide a practical framework for the management of patients with mRCC.
Spectrum ofBRAFMutations and Gene Rearrangements in Ovarian Serous Carcinoma
Authors: Chui M. Herman , Chang Jason C. , Zhang Yanming , Zehir Ahmet , Schram Alison M. , Konner Jason , Drilon Alexander E. , Da Cruz Paula Arnaud , Weigelt Britta , Grisham Rachel N.
Published: September 2021

PURPOSE

Low-grade serous carcinoma (LGSC) is a rare type of ovarian cancer, which commonly arises from serous borderline tumor (SBT) and is characterized by frequent activating mutations in the mitogen-activated protein kinase pathway, including BRAF. The BRAFV600Emutation is associated with improved prognosis in SBT and LGSC, and responses to BRAF inhibitor therapy have been reported. We sought to characterize the clinicopathologic and molecular features of BRAF-driven tubo-ovarian and primary peritoneal serous tumors.

METHODS

Retrospective analysis of our institutional cohort of SBTs (n = 22), LGSCs (n = 119) and high-grade serous carcinomas (HGSCs, n = 1,290) subjected to targeted massively parallel sequencing was performed to identify cases with BRAF genetic alterations. Putative BRAF rearrangements were confirmed using targeted RNA sequencing and/or fluorescence in situ hybridization (FISH). BRAFV600Eoncoprotein expression was assessed by immunohistochemistry on selected cases.

RESULTS

BRAF somatic genetic alterations were identified in 29 of 1,431 (2%) serous tumors and included mutations (n = 24), gene rearrangements (n = 3), and amplification (n = 2). BRAF mutations were more frequent in SBTs (7 of 22; 32%) compared with LGSCs (11 of 119; 9%, P = .009) and HGSCs (6 of 1,290; 0.5%; P < .0001, SBT/LGSC v HGSC). The BRAFV600Ehotspot mutation was most common (n = 16); however, other BRAF driver mutations were also detected (n = 8). BRAF mutations were often clonal or truncal in SBTs and LGSCs, but subclonal in most HGSCs. Pathogenic BRAF gene fusions were identified in LGSCs (n = 2) and HGSC (n = 1) and involved distinct fusion partners ( AGK, MKRN1, and AGAP3). Three patients with BRAF-mutant LGSC were treated with targeted mitogen-activated protein kinase inhibitors, one of whom was maintained on therapy for over 3 years with clinical benefit.

CONCLUSION

Recognition of BRAF alterations beyond V600E mutation in LGSC may have clinical implications for appropriate targeted therapy selection.
Retinal ganglion cell survival after severe optic nerve injury is modulated by crosstalk between Jak/Stat signaling and innate immune responses in the zebrafish retina
Authors: Chen Si , Lathrop Kira L. , Kuwajima Takaaki , Gross Jeffrey M.
Published: September 2021

Visual information is transmitted from the eye to the brain along the optic nerve, a structure composed of retinal ganglion cell (RGC) axons. The optic nerve is highly vulnerable to damage in neurodegenerative diseases, such as glaucoma, and there are currently no FDA-approved drugs or therapies to protect RGCs from death. Zebrafish possess remarkable neuroprotective and regenerative abilities. Here, utilizing an optic nerve transection (ONT) injury and an RNA-seq-based approach, we identify genes and pathways active in RGCs that may modulate their survival. Through pharmacological perturbation, we demonstrate that Jak/Stat pathway activity is required for RGC survival after ONT. Furthermore, we show that immune responses directly contribute to RGC death after ONT; macrophages/microglia are recruited to the retina and blocking neuroinflammation or depleting these cells after ONT rescues survival of RGCs. Taken together, these data support a model in which crosstalk between macrophages/microglia and RGCs, mediated by Jak/Stat pathway activity, regulates RGC survival after optic nerve injury.
YAP establishes epiblast responsiveness to inductive signals for germ cell fate
Authors: Kagiwada Saya , Aramaki Shinya , Wu Guangming , Shin Borami , Kutejova Eva , Obridge David , Adachi Kenjiro , Wrana Jeffrey L. , Hübner Karin , Schöler Hans R.
Published: September 2021

The germ cell lineage in mammals is induced by the stimulation of pluripotent epiblast cells by signaling molecules. Previous studies have suggested that the germ cell differentiation competence or responsiveness of epiblast cells to signaling molecules is established and maintained in epiblast cells of a specific differentiation state. However, the molecular mechanism underlying this process has not been well defined. Here, using the differentiation model of mouse epiblast stem cells (EpiSCs), we have shown that two defined EpiSC lines have robust germ cell differentiation competence. However, another defined EpiSC line has no competence. By evaluating the molecular basis of EpiSCs with distinct germ cell differentiation competence, we identified YAP, an intracellular mediator of the Hippo signaling pathway, as crucial for the establishment of germ cell induction. Strikingly, deletion of YAP severely affected responsiveness to inductive stimuli, leading to a defect in WNT target activation and germ cell differentiation. In conclusion, we propose that the Hippo/YAP signaling pathway creates a potential for germ cell fate induction via mesodermal WNT signaling in pluripotent epiblast cells.
Cost Effectiveness of Watch and Wait Versus Resection in Rectal Cancer Patients with Complete Clinical Response to Neoadjuvant Chemoradiation
Authors: Cui Christina Liu , Luo William Yu , Cosman Bard Clifford , Eisenstein Samuel , Simpson Daniel , Ramamoorthy Sonia , Murphy James , Lopez Nicole
Published: September 2021

Background

Watch and wait (WW) protocols have gained increasing popularity for patients diagnosed with locally advanced rectal cancer and presumed complete clinical response after neoadjuvant chemoradiation. While studies have demonstrated comparable survival and recurrence rates between WW and radical surgery, the decision to undergo surgery has significant effects on patient quality of life. We sought to conduct a cost-effectiveness analysis comparing WW with abdominoperineal resection (APR) and low anterior resection (LAR) among patients with stage II/III rectal cancer.

Methods

In this comparative-effectiveness study, we built Markov microsimulation models to simulate disease progression, death, costs, and quality-adjusted life-years (QALYs) for WW or APR/LAR. We assessed cost effectiveness using the incremental cost-effectiveness ratio (ICER), with ICERs under $100,000/QALY considered cost effective. Probabilities of disease progression, death, and health utilities were extracted from published, peer-reviewed literature. We assessed costs from the payer perspective.

Results

WW dominated both LAR and APR at a willingness to pay (WTP) threshold of $100,000. Our model was most sensitive to rates of distant recurrence and regrowth after WW. Probabilistic sensitivity analysis demonstrated that WW was the dominant strategy over both APR and LAR over 100% of iterations across a range of WTP thresholds from $0–250,000.

Conclusions

Our study suggests WW could reduce overall costs and increase effectiveness compared with either LAR or APR. Additional clinical research is needed to confirm the clinical efficacy and cost effectiveness of WW compared with surgery in rectal cancer.
New Strategy for Synthesis of Bis-Pocket Metalloporphyrins Enabling Regioselective Catalytic Oxidation of Alkanes
Authors: Amano Taisei , Inagaki Hideki , Shirakawa Yoshinori , Yano Yuuki , Hisamatsu Yosuke , Umezawa Naoki , Kato Nobuki , Higuchi Tsunehiko
Published: September 2021

Cytochrome P450 selectively hydroxylates the ω and ω-1 positions of fatty acids. Among synthetic oxidizing catalysts, Suslick’s bis-pocket porphyrin Mn or Fe complex achieved ω oxidation for the first time, but the yield in the preparation of the catalyst was poor due to steric hindrance, and in addition, the catalyst turnover number in the oxidation reaction was low. We have devised a new synthetic strategy involving the introduction of eight bulky aryl groups at the 2,6-positions of the meso-phenyl groups after construction of the porphyrin skeleton. This strategy greatly improved the yield in synthesis of the catalyst, and a number of derivatives of bis-pocket porphyrin and their metal complexes were prepared. These Ru complexes show unique ω-1 selectivity and provide a much higher turnover number in the oxidation of linear alkane with 2,6-dichloropyridine N-oxide, as compared to the reaction catalyzed by conventional Ru porphyrins.
As origens da deferência judicial às escolhas administrativas
Authors: Bamzai Aditya
Published: September 2021

A deferência judicial às escolhas administrativas — uma doutrina comumente associada à decisão da Suprema Corte no caso Chevron v. Conselho Natural — é um dos princípios centrais do direito público americano moderno. Apesar de seu significado, as origens e o desenvolvimento da doutrina são mal compreendidos. A Corte na Chevron alegou que as raízes da deferência judicial provêm de casos que datam do início do século XIX. Outros, ao contrário, procuraram localizar as raízes doutrinárias daChevron nas origens da revisão judicial no mandado de segurança. De acordo com a narrativa padrão, os tribunais na era pré-Chevron seguiram uma abordagem multifatorial e ad hoc para questões de deferência judicial; havia pouca teoria que explicasse os casos; e as decisões e o fundamento dos casos eram frequentemente contraditórios e difíceis de racionalizar.
A (in)constitucionalidade da desvinculação de receitas da União (DRU) ante o Princípio da Proibição de Retrocesso
Authors: Kossmann Edson Luís , Buffon Marciano
Published: September 2021

O presente artigo analisa a (in)constitucionalidade da desvinculação da receita da União, ante o princípio da proibição de retrocesso. Sustenta-se que os direitos fundamentais constitucionalmente consagrados e implementados não podem sofrer retrocesso. Isso em decorrência da recepção pelo direito brasileiro do chamado Princípio da Proibição de Retrocesso, consagrado nos documentos internacionais sobre direitos humanos, dos quais o Brasil é signatário. A DRU desvincula valores orçados e vinculados ao atendimento de direitos fundamentais como saúde, educação, assistência social, retirando dessas áreas valores essenciais para o atendimento daqueles direitos, mormente aqueles já implementados. Com isso ocorre um inevitável retrocesso no atendimento das demandas sociais e, consequentemente, tal desvinculação mostra-se inconstitucional.
Deferência judicial às escolhas regulatórias: o que podemos aprender com standards aplicados pela Suprema Corte estadunidense
Authors: Lirio do Valle Vanice Regina
Published: September 2021

Deferência judicial para com as escolhas administrativas regulatórias é matéria frequente nos escaninhos da Suprema Corte estadunidense, gerando um esforço consistente para a construção de standards de apreciação capazes de harmonizar a separação de poderes e um Estado administrativo funcional. Este artigo examina os precedentes principais que originaram esses standards de deferência judicial quando do controle de escolhas regulatórias, mapeando as categorias jurídicas que presidiram o razoamento da Corte. O objetivo é identificar semelhanças com a matriz de argumentação brasileira na matéria, beneficiando-se de uma fertilização recíproca sempre que possível.
Forte São Mateus e o Convento Nossa Senhora dos Anjos: da degradação à monumentalização nos processos de patrimonialização efetuados pelo IPHAN em Cabo Frio
Authors: Garrido Barbosa André Luiz
Published: September 2021

A presente reflexão tem por base o estudo de bens tombados pelo Instituto doPatrimônio Histórico e Artístico Nacional, na cidade de Cabo Frio no estado do Rio deJaneiro. No presente estudo teremos como eixo referencial a defesa e a religião noperíodo colonial. Desta forma, foram escolhidos como bens patrimoniais maisrepresentativos para análise do processo de patrimonialização efetuado pelo IPHANna cidade, o forte São Mateus e o Convento Nossa Senhora dos Anjos. Ao longo dotexto iremos procurar abordar aspectos relacionados a diferentes atribuições devalores e de sentidos aos monumentos analisados e elementos de sua historicidadepor meio dos processos de tombamentos: 0447-T-51 de 1951 e o 0757-T-65 de 1965.
Reinfection after COVID vaccination - The challenge is not yet over
Authors: Ahmed Shanila , Ali Noman
Published: September 2021

doi: https://doi.org/10.12669/pjms.37.7.5228

How to cite this:Ahmed S, Ali N. Reinfection after COVID vaccination-The challenge is not yet over. Pak J Med Sci. 2021;37(7):---------. doi: https://doi.org/10.12669/pjms.37.7.5228
Μελέτη του καρκινώματος από πλακώδες επιθήλιο της γλώσσας
Authors: Κολούτσος Γεώργιος
Published: September 2021

Ο καρκίνος της γλώσσας από πλακώδες επιθήλιο της στοματικής γλώσσας συνιστά το μεγαλύτερο μέρος των νέων περιστατικών καρκινώματος από πλακώδες επιθήλιο της στοματικής κοιλότητας που εμφανίζονται κάθε χρόνο διεθνώς. Παρά την πρόοδο της Ιατρικής επιστήμης δεν έχει συμβεί σημαντική πρόοδος στην επιβίωση των ασθενών αυτών τις τελευταίες δεκαετίες και η επιστημονική έρευνα πλέον στρέφεται γύρω από την εντόπιση παραγόντων, που να μπορούν να βοηθήσουν στην εκτίμηση της πρόγνωσης. Στα πλαίσια αυτά και με δεδομένο το λεμφογενές μεταστατικό δυναμικό που χαρακτηρίζει την νόσο εστιάσαμε στο αντίσωμα D2-40 έναντι της Ποδοπλανίνης, το οποίο χρησιμοποιείται στην ανοσοϊστοχημεία και έχει φανεί πως προσλαμβάνεται από τα ενδοθηλιακά κύτταρα των λεμφαγγείων, όπου ακριβώς φαίνεται πως εκφράζεται η σιαλογλυκοπρωτεΐνη αυτή. Το υλικό της παρούσας μελέτης αποτελούνταν από 63 ασθενείς με καρκίνωμα από πλακώδες επιθήλιο της στοματικής γλώσσας, οι οποίοι αντιμετωπίστηκαν στην κλινική της Στοματικής και Γναθοπροσωπικής Χειρουργικής του Γενικού Νοσοκομείου Θεσσαλονίκης «Γ.ΠΑΠΑΝΙΚΟΛΑΟΥ» από το 2000 ως το έτος 2010 και των οποίων οι φάκελοι μελετήθηκαν αναδρομικά. Έγινε διερεύνηση της έντασης και της έκτασης της πρόσληψης του αντισώματος D2-40 από τα νεοπλασματικά κύτταρα σε διαγνωστικές τομές από εγκυβωτισμένα σε παραφίνη, μονιμοποιημένα με φορμαλδεΰδη παρασκευάσματα και στη συνέχεια στατιστική επεξεργασία επιδημιολογικών και παθολογοανατομικών παραμέτρων του υλικού (ηλικία, φύλο, μέγεθος πρωτοπαθούς εστίας, βαθμός διαφοροποίησης, βάθος διήθησης, πάχος του όγκου, ύπαρξη μετάστασης στον τράχηλο). Από τη μελέτη και τη στατιστική επεξεργασία των δεδομένων, το φύλο, η ηλικία, το μέγεθος της πρωτοπαθούς εστίας και ο βαθμός διαφοροποίησης απέτυχαν να συνδεθούν στατιστικά σημαντικά με την πρόγνωση και την επιβίωση των ασθενών)( Log Rank[Mantel-Cox] sig. 0.700, 0.417, 0.553, 0.760 αντίστοιχα). Το ίδιο αποτέλεσμα είχε και η μελέτη του αντισώματος D2-40 και πιο συγκεκριμένα τόσο η έκταση του καρκινώματος που το προσλάμβανε όσο και η ένταση με την οποία τα νεοπλασματικά κύτταρα την προσλάμβαναν, δεν μπόρεσαν να συνδεθούν στατιστικά σημαντικά με την πρόγνωση και την επιβίωση (Log Rank[Mantel-Cox]sig. 0.533 και 0.091 αντίστοιχα). Αντίθετα η ύπαρξη λεμφαδενικής μετάστασης στον τράχηλο φάνηκε πως επηρεάζει σημαντικά την επιβίωση (Log Rank(Mantel-Cox] sig.<0.0001) ενώ τόσο το πάχος του όγκου, όσο και το βάθος της διήθησης φάνηκαν να συνδέονται στατιστικά σημαντικά με αυτήν (sig. 0.002 και 0.023 αντίστοιχα). Σε συμφωνία με τα διεθνή βιβλιογραφικά δεδομένα η ύπαρξη λεμφαδενικής μετάστασης στον τράχηλο αποδείχθηκε ο πιο σημαντικός προγνωστικός παράγοντας όσον αφορά την επιβίωση του ασθενούς. Το αντίσωμα D2-40 έναντι της Ποδοπλανίνης δεν έδειξε καμία στατιστικά σημαντική συσχέτιση ούτε με την ύπαρξη μετάστασης στον τράχηλο αλλά ούτε και με την επιβίωση των ασθενών στο υλικό μας.
Το δικαίωμα πρόσβασης στα έγγραφα στην ελληνική και κοινοτική έννομη τάξη
Authors: Θεοφυλάκτου Βαρβάρα
Published: September 2021

Η διατριβή πραγματεύεται το θεσμικό πλαίσιο της πρόσβασης στις περιβαλλοντικές πληροφορίες στην ελληνική και κοινοτική (ενωσιακή) έννομη τάξη. Διερευνάται ειδικότερα η μετά από αίτηση του ενδιαφερομένου πρόσβαση στα έγγραφα που διαθέτουν οι εθνικές δημόσιες αρχές και τα ευρωπαϊκά θεσμικά όργανα και περιέχουν περιβαλλοντικές πληροφορίες, ως ειδικότερη πτυχή της πρόσβασης στα διοικητικά έγγραφα. Η θεσμική κατοχύρωση και η εξασφάλιση της δυνατότητας των ενδιαφερομένων να λαμβάνουν γνώση των πληροφοριών που αφορούν το περιβάλλον έχει διττή σημασία η οποία συνοψίζεται στο δίπτυχο «διαφάνεια – περιβαλλοντική προστασία». Η πρόσβαση στις περιβαλλοντικές πληροφορίες συνιστά παράγοντα διαφάνειας της δράσης της διοίκησης και αναμφισβήτητο προαπαιτούμενο για την επιδίωξη της συμμετοχής των πολιτών στην λήψη των αποφάσεων, ενώ συνδέεται με την προστασία του περιβάλλοντος ως εθνική και ενωσιακή πολιτική και με το δικαίωμα στο περιβάλλον. Λαμβάνοντας υπόψη το υφιστάμενο θεσμικό πλαίσιο, σε διεθνές, ενωσιακό και εθνικό επίπεδο επιχειρείται να απαντηθεί το ερώτημα, κατά πόσον οι ειδικοί κανόνες του διεθνούς και ενωσιακού δικαίου για την πρόσβαση στις περιβαλλοντικές πληροφορίες διαφοροποίησαν το γενικό νομικό πλαίσιο πρόσβασης στα διοικητικά έγγραφα και, περαιτέρω, εάν συνέβαλαν στην ενίσχυση της διαφάνειας και στην επίτευξη υψηλότερου βαθμού περιβαλλοντικής προστασίας. Επίσης, ερευνάται κατά πόσον το υφιστάμενο νομοθετικό πλαίσιο παρέχει επαρκή ερείσματα για την θεμελίωση του δικαιώματος πρόσβασης στις περιβαλλοντικές πληροφορίες και ποια είναι η φύση του εν λόγω δικαιώματος.
Η ιστορία της διασωλήνωσης και του μηχανικού αερισμού
Authors: Πασσιάς Απόστολος
Published: September 2021

Η σημασία της προστασίας του αεραγωγού είχε γίνει αντιληπτή από τηναρχαιότητα. H χειρουργική τεχνική της τραχειοτομής είναι πολύ παλιά καιπροστατεύει τον αεραγωγό. Οι πρώτες γνωστές αναφορές στην τραχειοτομήέγιναν στο ιερό βιβλίο « Rigventa» των Hindu που γράφηκε πριν 4000χρόνια. Η στοματοτραχειακή διασωλήνωση, ο άλλος τρόπος διασφάλισης τουαεραγωγού, περιγράφηκε αργότερα. Αυτές είναι οι κύριες μέθοδοιεξασφάλισης του αεραγωγού που στην μακραίωνη ιστορία τους προτάθηκαν,εφαρμόστηκαν αλλά και ξεχάστηκαν πολλές φορές ως την αποδοχή τουςστην καθημερινή πρακτική. Η υιοθέτησή τους βοηθήθηκε από την απόκτησηγνώσεων και την τεχνολογική πρόοδο που πρόσφερε τον κατάλληλο καιασφαλή εξοπλισμό για την εφαρμογή τους. Οι ερευνητές τελειοποίησαν τοντραχειοσωλήνα, το λαρυγγοσκόπιο ενώ αθροίστηκε γνώση πάνω στηνφυσιολογία των πνευμόνων και της αναπνοής.Η σημασία της αναπνοής έγινε κατανοητή τον 5ο αιώνα π.Χ. από τον Διογένητον Απολλωνιάτη. Έναν αιώνα αργότερα ,4ο αιώνα π.Χ., ο Πλάτωνας και οΑριστοτέλης επισημαίνουν την σημασία της αναπνοής για την ζωή. Αρκετάχρόνια αργότερα , τον 15ο αιώνα μ.Χ., ξεκινά η ιστορία του αερισμού τωνπνευμόνων με τεχνικά μέσα. Σημαντική έκρηξη γίνεται τον 18-19ο αιώνα μ.Χ.με την ανάπτυξη της έρευνας για αναζωογόνηση θυμάτων πνιγμού.Εμπλέκονται επιστήμονες, γιατροί και φυσιολόγοι της εποχής. Αρχικά,χρησιμοποιήθηκαν φυσερά δηλαδή αερισμός θετικών πιέσεων, όμως τοπρόβλημα του πνευμοθώρακα και η αδυναμία να εξασφαλιστεί ο αεραγωγόςεμπόδισε την αποδοχή του αερισμού θετικών για δεκαετίες. Σαν συνέπεια, ηπροσπάθεια ανάπτυξης του μηχανικού αερισμού κατευθύνθηκε στην κατασκευή αξιόπιστων αναπνευστήρων, της ασφαλέστερης, αρνητικής πίεσης. Μια σημαντική στιγμή για τον μηχανικό αερισμό είναι οι επιδημίες πολιομυελίτιδας που ξεσπούν στην Ευρώπη και στις Ηνωμένες Πολιτείες . Η υιοθέτηση των πρακτικών προστασίας του αεραγωγού και η χρήση τουκουραρίου στην αναισθησιολογική πρακτική, οδήγησε στην εφαρμογήελεγχόμενου αερισμού θετικών πιέσεων και την δημιουργία αξιόπιστωναναπνευστήρων. Σταδιακά δημιουργήθηκαν καλύτεροι αναπνευστήρες καιασφαλέστερα μοντέλα υποστήριξης της αναπνοής. Κατά την διάρκεια των επιδημιών έγιναν και οι πρώτες παρατηρήσεις για βλάβες στους πνεύμονες από τον μηχανικό αερισμό.
Σύσταση και λειτουργία πανευρωπαϊκού δικτύου κέντρων αριστείας (centers of excellence) στη βαριατρική χειρουργική
Authors: Σταυρουλάκης Κωνσταντίνος
Published: September 2021

Παρά τη μεγάλη διάδοση και εφαρμογή προτύπων διαπίστευσης και πιστοποίησης της ποιότητας και την παγκόσμια αποδοχή τους, η εισαγωγή συστημάτων διαχείρισης της ποιότητας στους δημόσιους και ιδιωτικούς οργανισμούς παροχής υπηρεσιών υγείας ως προς τις παρεχόμενες ιατρικές υπηρεσίες τους δεν έχει έως και σήμερα επαρκώς κωδικοποιηθεί και διαδοθεί. Αντικείμενο της διπλωματικής εργασίας είναι η διερεύνηση των συνεπειών της σύστασης και λειτουργίας ενός Πανευρωπαϊκού δικτύου Κέντρων Αριστείας στην Βαριατρική Χειρουργική ως προς τη διάδοση προτύπων πιστοποίησής της ποιότητας σε οργανισμούς παροχής υπηρεσιών υγείας, και ως προς την αποδοχή της αναγκαιότητας διαπίστευσης των υπηρεσιών υγείας. Δευτερευόντως, εξετάζονται ζητήματα που αφορούν τη διαθεσιμότητα και διάδοση προτύπων πιστοποίησής της ποιότητας στην υγεία και των ωφελημάτων που εισπράττουν οι ασθενείς, τα νοσηλευτικά ιδρύματα και τα συστήματα υγείας από την πιστοποίηση των υπηρεσιών υγείας. Στην αρχή της εργασίας γίνεται μια εισαγωγή για την έννοια και τον ορισμό της ποιότητας στην υγεία καθώς και για τα ποιο διαδεδομένα συστήματα διαχείρισης ποιότητας στις υπηρεσίες υγείας. Εν συνεχεία η εργασία επικεντρώνεται στη διαπίστευση της ποιότητας στη Βαριατρική Χειρουργική, καθώς στο πεδίο της Βαριατρική Χειρουργικής υφίσταται πρότυπο διαπίστευσης της ποιότητας των παρεχόμενων ιατρικών υπηρεσιών σε Ηνωμένες Πολιτείες Αμερικής (ΗΠΑ), Ευρωπαϊκή Ένωση (ΕΕ), Αραβικές Χώρες και Αφρική. Η μελέτη εστιάζει στην διερεύνηση του προτύπου «Κέντρα Αριστείας» που παρέχεται από το European Accreditation Council for Bariatric Surgery (EAC-BS) στην Ευρωπαϊκή Ένωση, Αφρική και τις Αραβικές Χώρες. Παρουσιάζεται η δομή του προτύπου ενώ γίνεται και περιληπτική αναφορά στις απαιτήσεις του προτύπου. Επιπλέον, περιγράφεται η διαδικασία που πρέπει να ακολουθήσουν τα νοσηλευτικά ιδρύματα και οι ιατροί για να πιστοποιηθούν. Ακολούθως, αξιολογούνται συγκριτικά τα στοιχεία του αρχείου του EAC-BS για δύο βασικές τεχνικές βαριατρικής χειρουργικής την επιμήκη γαστρεκτομή (sleeve gastrectomy) και την γαστρική παράκαμψη (gastric bypass). Από την συγκριτική αξιολόγηση των αποτελεσμάτων της επιμήκους γαστρεκτομής (sleeve gastrectomy) και της γαστρικής παράκαμψης (gastric bypass) αποδεικνύεται αφενός ότι τα νοσηλευτικά ιδρύματα και οι χειρουργοί που πληρούν τα κριτήρια ασφάλειας του International Federation for the Surgery of Obesity (IFSO) και έχουν πιστοποιηθεί από τον EAC-BS για την εφαρμογή Συστήματος Διαχείρισης Ποιότητας (ΣΔΠ) στη Βαριατρική Χειρουργική, εφαρμόζουν τις δύο παραπάνω βασικές τεχνικές βαριατρικής χειρουργικής με τη μέγιστη δυνατή ασφάλεια και το βέλτιστο δυνατό αποτέλεσμα για τον ασθενή. Επιπρόσθετα, προκύπτει η βέλτιστη συγκριτικά τεχνική σε σχέση με την ικανοποίηση των απαιτήσεων των ασθενών και την βελτίωση της ποιότητας της ζωής τους.
Δείκτες μέτρησης ποιότητας της αφηγηματικής πληροφόρησης των χρηματοοικονομικών καταστάσεων πριν και μετά την εισαγωγή των διεθνών λογιστικών προτύπων
Authors: Γαρεφαλάκης Αλέξανδρος
Published: September 2021

Η έρευνα για την ποιότητα της ετήσιας έκθεσης χρηματοοικονομικών καταστάσεων και συγκεκριμένα του τμήματος των αφηγηματικών/λεκτικών πληροφοριών που ενυπάρχουν σε αυτήν έχει από καιρό υποτιμηθεί, κυρίως λόγω της έλλειψης κατάλληλων δεικτών που να επιτρέπουν μια αντικειμενική μέτρηση και ανάλυση των αφηγηματικών πληροφοριών των επιχειρήσεων. Η εργασία αυτή εστιάζει στην μέτρηση της ποιότητας του αφηγηματικού μέρους των χρηματοοικονομικών καταστάσεων, με τη χρήση δύο προτεινόμενων σύνθετων δεικτών, του μη-σταθμισμένου δείκτη Ma.Co.I και του σταθμισμένου δείκτη Ma.Co.Iw, σε μια πολύ σημαντική μεταβατική περίοδο αλλαγών για τα διεθνή λογιστικά πρότυπα αλλά και για τα πρότυπα της αφηγηματικής πληροφόρησης. Η μεταβατική περίοδος αυτή, ορίζεται, πριν την εφαρμογή των Διεθνών Λογιστικών προτύπων (2002-2004) και μετά την εφαρμογή των Διεθνών Λογιστικών προτύπων (2005-2007), ενώ οι γεωγραφικές περιοχές που επιλέχθηκαν ήταν η Βόρεια Ευρώπη, η Δυτική Ευρώπη και η ΗΠΑ. Τα αποτελέσματα της έρευνας δείχνουν ότι μετά την υιοθέτηση των Διεθνών Λογιστικών προτύπων (ΔΛΠ), υπήρξε βελτίωση στην ποιότητα των ετήσιων χρηματοοικονομικών καταστάσεων. Ωστόσο, η βελτίωση αυτή αποτυπώθηκε περισσότερο στις οικονομικές πληροφορίες στο ποσοστό του 35% σε αντίθεση με τις Περιβαλλοντικές, Κοινωνικές και Εταιρικής διακυβέρνησης πληροφορίες (ESG-Environmental, Social and Governance) όπου η αύξηση τους κυμάνθηκε κατά μέσο όρο στο ποσοστό του 20%.Παρά τη συνεχιζόμενη ζήτηση των επενδυτών για περισσότερη ποιότητα στην δημοσιευμένη χρηματοοικονομική έκθεση των εταιρειών, στο δείγμα που επιλέχθηκε στο πλαίσιο της παρούσας έρευνας, ένας μεγάλος αριθμός επιχειρήσεων φαίνεται να μην συγκλίνει προς αυτή την κατεύθυνση αλλά να επενδύει σε τεχνικές διαχείρισης εντυπώσεων και απόκρυψης της πληροφόρησης αυτής. Οι εν λόγω τεχνικές ερευνήθηκαν στην συγκεκριμένη διδακτορική διατριβή (Δ.Δ), με την χρήση της μεθόδου των ελαχίστων τετραγώνων (OLS) εξετάζοντας συγκεκριμένους παράγοντες που μπορεί να επηρεάζουν την ποιότητα των ετήσιων χρηματοοικονομικών εκθέσεων, δίνοντας σημαντικά και ποικίλα συμπεράσματα. Τέλος, η γεωγραφική περιοχή των ΗΠΑ η οποία εφαρμόζει υποχρεωτικά τους κανόνες του αφηγηματικού πλαισίου “Συζήτηση και Ανάλυση της Διαχείρισης” (MD&A - Management Discussion & Analysis , δεν διαφαίνεται να προσφέρει σημαντική βελτίωση ως προς την ποιότητα των χρηματοοικονομικών καταστάσεων, σε σχέση με τις εταιρείες που δραστηριοποιούνται στην Ευρώπη (Βόρεια και Δυτική Ευρώπη), στις οποίες η υιοθέτηση του αφηγηματικού πλαισίου είναι προαιρετική. Λαμβάνοντας ως σημαντικό μήνυμα ότι οι υποχρεωτικοί κανόνες αφηγηματικής πληροφόρησης δεν είναι απαραίτητα και δίαυλοι ποιοτικότερης πληροφόρησης, αλλά οι εκάστοτε εταιρείες μπορούν να γίνουν με την θέληση τους περισσότερο αξιόπιστες προς τα ενδιαφερόμενα μέλη τους.