No study has reported an animal model of uterus transplantation (UTx) using cynomolgus macaques. We aimed to establish a surgical technique of allogeneic UTx assuming the recovery of a uterus from a deceased donor in cynomolgus macaques. Four allogeneic UTxs were performed in female cynomolgus macaques. Donor surgeries comprised en bloc recovery of organs with iliac vessels on both sides, and/or abdominal aorta/vena cava after sufficient perfusion from one femoral artery or external iliac artery. Before perfusion, 150 mL of whole blood was obtained from the donor for subsequent blood transfusion to the recipient. Four uterine grafts were orthotopically transplanted to recipients. End-to-side anastomosis was performed to the iliac vessels on one side in case 1 and iliac vessels on both sides in case 2; aorto-aorto/cavo-caval anastomosis was performed in cases 3 and 4. Arterial blood flow of the uterine grafts was determined by intraoperative indocyanine green (ICG) angiography. ICG angiography results showed sufficient blood flow to all uterine grafts, and anaemia did not progress. Under appropriate immune suppression, all recipients survived for more than 90 days post-transplantation, without any surgical complications. We describe a surgical technique for allogeneic UTx in cynomolgus macaques. Therefore, we aimed to establish a surgical technique of allogeneic UTx assuming the recovery of a uterus from a deceased donor in cynomolgus macaques.Macaca fascicularis,  with regular menstrual cycles were used. The animals (n = 9) were either donors or recipients, depending on their blood type and body weight  and an artery line  were respectively inserted into the left internal or external jugular vein and the left common carotid artery, which were surgically exposed. Thereafter, thoracolaparotomy was performed, and the vessels of the abdominal aorta, vena cava, and those surrounding the uterus were decorticated. Subsequently, the ureters were mobilized from the bladder to the kidneys to enable full access to the uterine and ovarian veins in cases 1 and 2, and then the ureters were immobilized from the uterine arteries, uterine veins, and ovarian veins to prevent vasospasms and injury to the vessels in cases 3 and 4. The vault of the vagina, uterus, and fallopian tubes were completely mobilized with their arterial inflows and venous outflows, including the infrarenal abdominal aorta and IVC (cases 3 and 4), iliac vessels, and ovarian arteries and veins. All iliac vessel branches proximal to the site of the external iliac vessel, which was planned to be resected after perfusion, were ligated and transected with all lumbar branches of the abdominal aorta and IVC, up to the level of aortic bifurcation (cases 1 and 2) or the renal vessels (cases 3 and 4).®; Custodiol®, Nordmedica, Gentofte, Denmark) via the catheter in the femoral or external iliac artery.After completing all mobilizations, a perfusion catheter  was inserted into one femoral artery or external iliac artery. Before perfusion, 150 mL of whole blood was withdrawn from the femoral artery or external iliac artery catheter for subsequent blood transfusion to the recipient animal. To maintain the blood pressure of the donor animal, whole blood was withdrawn with rapid intravenous infusion of Ringer’s solution. Immediately after bloodletting, an anticoagulant  was administered intravenously. Five minutes later, the abdominal aorta just below the diaphragm was cross-clamped, and the IVC was cut in the pleural space. Simultaneously, the abdominal and pelvic cavities were filled with crushed ice to cool the abdominal organs. Whole organs, including the uterine graft, were perfused with 200–350 mL of cold histidine-tryptophan-ketoglutarate solution  or abdominal aorta/IVC above the left renal vein (cases 3 and 4) were also transected ,B. Then One hundred fifty millilitre of whole blood, diluted by infusion load, was collected from the donor and stored in an anticoagulant bag including a citrate-phosphate-dextrose solution with adenine . After leukocytes were depleted using leukoreduction filter sets , the blood was irradiated (30 Gy) to prevent graft-versus-host disease. This stored donor blood was transfused into each recipient animal during vascular anastomosis and/or after reperfusion of the uterine graft.Intraoperative indocyanine green (ICG) was injected intravenously, and the blood supply of organs was monitored at intervals as previously described®; Kono Seisakusho, Co., Ltd., Chiba, Japan). Subsequently, iliac vessels on both sides (cases 1 and 2) or the infrarenal abdominal aorta/IVC (cases 3 and 4) was exposed at a distance of approximately 1.5 cm to enable end-to-side anastomosis of the uterine graft vessels.Recipient surgery was initiated about 5 hours after starting the donor surgery to reduce the cold storage time of the uterine graft and shorten the graft waiting time as much as possible. After entering the peritoneal cavity through a midline incision, a total simple hysterectomy was performed, with preservation of the ovaries. The vaginal vault was left open by placing stay sutures on its anterior and posterior wall  to fix the uterus in the pelvis before performing vascular anastomoses. To keep the graft cold, ice slush was placed around the graft. Before vascular anastomoses, heparin (100 IU) was administered intravenously. After the iliac vein or IVC was cross-clamped, a longitudinal venotomy was made, and end-to-side venous anastomosis was performed using continuous sutures . Thereafter, the iliac artery or infrarenal abdominal aorta was cross-clamped, and a longitudinal arteriotomy was made. End-to-side arterial anastomosis was also performed using continuous sutures   . After cAs an induction treatment, the animals received antithymocyte globulin (ATG)  intravenously on post-operative day (POD) 0 (day 0 defined as the day of surgery) in cases 1 and 2 and on POD 0 and POD 2 in cases 3 and 4. Maintenance treatment consisted of cyclosporine (CyA)  in cases 1 and 2 and tacrolimus (TAC)  in cases 3 and 4. The target trough levels for CyA and TAC up to 1 month after the surgery were planned to be within the range of 300–400 ng/mL and 15–20 ng/mL, respectively. As another maintenance treatment, mycophenolate mofetil (MMF)  was administered orally in cases 1, 3, and 4. Methylprednisolone  was injected intravenously on POD 0 and was injected intramuscularly daily, starting on POD 1. The dose of methylprednisolone was gradually tapered, and the administration was completed on POD 14 in cases 1 and 2. In cases 3 and 4, 0.5 mg/kg and 0.2 mg/kg of methylprednisolone were administered continuously until the end of observation, respectively.To monitor for potential rejection after the surgery, the size of the transplanted uterus and blood flow in the transplanted uterine artery were determined by transabdominal ultrasonography under anesthesia. Transvaginal biopsy of the transplanted uterine cervix and body was routinely conducted more than once a month or when considered necessary.Nine animals were used in this study . In case 1, because an animal of a recipient candidate exhibited severe aspiration pneumonia at an early stage of the surgery, another animal was selected as an alternate recipient immediately after euthanizing the first recipient animal.The background and surgical details of the four donor animals are shown in With organ perfusion, gross findings in the donor animals showed a change in colour from red to white in all abdominal organs, indicating favourable perfusion of the uterus and all other organs. The duration of the retrieval surgeries (n = 4) averaged 7 hours 23 minutes ± 19 minutes (mean ± standard deviation).In the first two transplants, end-to-side anastomoses of the iliac vessels were performed. In case 1 (a substitute recipient was used because the first recipient had a respiratory problem), only anastomosis of the right iliac vessels on one side was performed since there was not enough time to complete both sides because respiratory acidosis rapidly progressed in the new recipient during surgery. In case 2, anastomoses of the iliac vessels on both sides were performed under stable conditions. In cases 3 and 4, end-to-side aorto-aorto and cavo-caval vascular anastomoses were performed .In all four recipients, good blood flow through the organ occurred immediately after reperfusion, showing a transition in colour in the uterus from whitish to reddish and pulsations through the uterine artery without uterine congestion . ICG fluThe cold ischemic time  was 45 minutes ± 3 minutes (mean ± standard deviation), and the warm ischemic time  was 1 hour 50 minutes ± 12 minutes (mean ± standard deviation). This excluded case 1 because the recipient was replaced with another animal during surgery. The surgical parameters of the recipients are also summarized in All four recipient animals survived for more than 3 months after the surgery without any surgical complications. Although rejection was diagnosed in the biopsy samples within 1 month after the surgery in case 4, within 2 months in case 2 and within 3 months in cases 1 and 3, transabdominal ultrasonography showed pulsatile arterial blood flow in the transplanted uterine artery within 1 month after surgery in all cases . HoweverThe stored donor blood was transfused into each recipient animal. Changes in the whole blood haemoglobin level in the recipient animals are shown in Vascular reconstruction in recipient animals may be easier in deceased-donor models than in living-donor models because much larger vessels could be used for vascular reconstruction in deceased-donor animal models. Recently, we reported a preliminary study of a new perfusion method for UTx with assumed uterus retrieval and preservation from a deceased donor in cynomolgus macaquesAlthough in cases 1 and 2, vascular anastomosis of the ovarian vein of the transplanted uterus was not performed, we were able to establish drainage of venous blood of the uterus through the ovarian vein after UTx in cases 3 and 4 by en bloc extraction of either the left renal vein or IVC, into which the ovarian vein flows. We previously reported that the ovarian vein is an important drainage vein in uterine circulationThere have already been several reports of animal models using anastomosis of the aorta and IVC1718There are a couple limitations in this study. First, we used an animal model; thus, not all parts of the techniques are applicable to clinical settings. Second, factors associated with the long-term outcomes  are in progressIn our study of allogeneic UTx assuming the recovery of a uterus from a deceased donor in cynomolgus macaques, we successfully created a stable allogeneic transplantation technique by performing vascular anastomosis with major blood vessels and administering an intraoperative transfusion of donor blood to the recipient.How to cite this article: Obara, H. et al. Surgical technique for allogeneic uterus transplantation in macaques. Sci. Rep.6, 35989; doi: 10.1038/srep35989 (2016).Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


Increased aortic stiffness has been recognized as a predictor of adverse cardiovascular outcomes in some clinical conditions, such as in patients with arterial hypertension and end-stage renal disease, in population-based samples and, more recently, in type 2 diabetic patients. Patients with type 2 diabetes have higher aortic stiffness than non-diabetic individuals, and increased aortic stiffness has been correlated to the presence of micro- and macrovascular chronic diabetic complications. We aimed to review the current knowledge on the relationships between aortic stiffness and diabetic complications, their possible underlying physiopathological mechanisms, and their potential applications to clinical type 2 diabetes management. The role of aortic stiffness in the pathogenesis of cardiovascular diseases has been increasingly recognized in the last decade ,2. ArterType 2 diabetic patients have increased aortic stiffness ,15,16 anTherefore, we review the recent evidence regarding aortic stiffness as a predictor of cardiovascular morbidity and mortality and of development and progression of microvascular complications in patients with type 2 diabetes. Furthermore, we address possible physiopathological mechanisms regarding the associations between increased aortic stiffness and the occurrence of macro- and microvascular complications in type 2 diabetes.Increased aortic stiffness, measured by carotid–femoral PWV, has been well-demonstrated to represent an independent predictor of future major cardiovascular events occurrence in several clinical settings, such as in arterial hypertensive patients ,35, in pThese studies enforce the importance of aortic stiffness as a predictor of cardiovascular morbidity and mortality in patients with type 2 diabetes. Moreover, carotid–femoral PWV measurement is a relatively simple, moderate-cost method, with a well-standardized procedure and equipment ,43 and wThe presence of diabetic microvascular complications  have all been widely reported as independently associated with higher arterial stiffness in cross-sectional analyses ,30,31,32Recently, we have reported on the determinants of increasing or reducing (“de-stiffening”) aortic stiffness on a long-term follow-up study with two carotid–femoral PWV measurements performed over a median of 4.2 years . The maiOn the other hand, longitudinal studies investigating the relationships between aortic stiffness and the future occurrence of microvascular diabetic complications are scarce ,34. ReleThe physiopathological mechanisms associating augmented aortic stiffness to cardiovascular outcomes remain largely unsettled. The most accepted hypothesis is that a high aortic stiffness causes a precocious backward pulse wave return during systole and consequently higher systolic and lower diastolic central pressures. This phenomenon provokes an augment in left ventricular workload, and subsequent left ventricular hypertrophy and a reduction in coronary perfusion, potentially causing myocardial ischemia. However, this assumption has been disputed because of the fact that aortic PWV has been demonstrated to be an important prognostic cardiovascular risk marker, but not a measure of central aortic pressure or of backward pulse wave reflection . AlternaOn the other hand, the potential physiopathological mechanisms linking increased aortic stiffness to diabetic microvascular disease development is still mainly speculative. As discussed before, the presence of diabetic microvascular complications is a predictor of future worsening of aortic stiffness , whereas1c) levels in cross-sectional investigations [1c levels and aortic stiffness progression/regression, which may be in part intermediated by AGEs formation. Long-term hyperglycemia augments the reaction between glucose and proteins and yields cross-linking of collagen, elastin and other molecules, so-called AGEs, which have been demonstrated to promote collagen accumulation, tissue inflammation and fibrosis within the wall of the blood vessels [1c values may be associated with an increase in aortic stiffness, pentosidine levels (a well-delineated AGE) were independently related to the progression of aortic stiffness in diabetic patients on hemodialysis followed up for 1.2 years [Another potential explanation linking increased arterial stiffness to diabetic microvascular complications development is that they may share common physiopathological pathways. Two physiopathological pathways emerge as potentially involved in this association: advanced glycation end-products (AGEs) formation and renin–angiotensin system overactivation. Increased aortic stiffness is accepted to be related to quantitative and qualitative changes in the arterial wall content of elastin and collagen ,2. Evideigations ,53, and igations . This su vessels . Long-te vessels . Further vessels . Giving .2 years .Otherwise, the renin–angiotensin system (RAS) is over-activated at the vascular wall in conditions of aging, atherosclerotic alterations and in diabetes . RAS actThere are several potential pharmacological and non-pharmacological interventions aiming to reduce (“de-stiffening”) aortic stiffness. Regarding possible effects of weight loss on arterial stiffness, a meta-analysis involving 1259 patients suggested that modest weight loss (mean 8%) achieved with diet and lifestyle measures may reduce arterial stiffness . AlthougAortic stiffness is increased in patients with type 2 diabetes and it is related to the presence of diabetic micro- and macrovascular complications. Further, it has been demonstrated to be an independent predictor of worse cardiovascular outcomes in type 2 diabetic patients and also a risk marker for diabetic nephropathy and peripheral neuropathy onset and progression. However, the physiopathological mechanisms linking increased aortic stiffness and the occurrence of diabetic vascular complications still remain unclear. Based on current evidence, we recommend routinely evaluating aortic stiffness by its gold standard method, the carotid–femoral PWV measurement, which is a relatively simple, moderate-cost, and well-standardized procedure. Evidence that optimal glycemic and blood pressure control is associated with attenuation/prevention of progression of aortic stiffness needs to be confirmed on future randomized studies, as well as whether other interventions can reduce aortic stiffness and improve morbidity and mortality in patients with type 2 diabetes.


In recent decades the Brazilian cardiovascular surgery has made milestones, anextraordinary evolution occupying a prominent position in the international scenario,with a significant increase in volume of surgical procedures, development of newsurgical techniques and a local industry that supported this rise.Similarly, the union of cardiovascular surgeons enabled the construction of a strong andthriving specialty society, which has served as a model for other guilds over thecountry by the vigor in the defense of their rights, achievements and attainedleadership.In the wake of these journeys, 30 years ago the Brazilian Journal of CardiovascularSurgery was launched, consolidating its position as the official journal for promotingthe scientific production of the Brazilian cardiovascular surgeons. With strongleadership working hard as editors, continuous developments and changes contributed tothe journal reached this position, from the early conquests with the inclusion in Scieloportal allowing the electronic version in Portuguese and spread on the Internet to theinclusion and availability in the CTSNet portal, the Internet page of cardiovascularsurgeons from around the world.The indexing in Medline / Pubmed, the most important scientific database on the planet inhealth sciences, represented the maturity of the publication project and confidence inthe evolution of quality.But crucial decisions were made about the way to go, after long and exhaustive analysis.With globalization and the consequent need for dissemination of its scientific content,the adoption of the English language was natural and imperative to achieve this goal.Breaking the paradigm of a regional publication evolving to show up on the world stage.The change of the name to Brazilian Journal of Cardiovascular Surgery stood also for achallenge, with the scope to internationalize the journal and places it to assume a morerepresentative position in the cardiovascular arena. To accomplish this goal, Englishlanguage translation or editing service has been provided for authors who are not fluentin this idiom, assisting to prepare a publication-ready.Just like the other periodicals, the BJCVS strive to publish significant and high-qualityoriginal scientific papers, which will serve for further interest in citation andtherefore increasing the impact factor. The impact factor ranks the scientificexcellence of the periodicals worldwide and all the efforts are focused to reach thequality level attained by the top publications in the field.And the adoption of a new software of electronic submission, the Scholar One is intendedto facilitate to local and overseas authors the straightforward submission of themanuscript, avoiding delays and expediting the publication.The publication has been expanded for six issues a year, and the continuing medicaleducation (CME) is provided in every issue, where the editor picks the article and writethe related multiple choice questions.Expanding the scope, the BJCVS also has served for publication of original works frommultidisciplinary or multiprofessional production, specialties and professionals ofrelated areas working along cardiovascular surgeons and making possible achieve the highstandard of healthcare and scientific excellence.Seven associate editors have been assigned to assist in every sub-area of thecardiovascular surgery with the review of different types of manuscripts, selectreviewers, review reviews, and make the final decision to accept, reject, or revise.Moreover, a new team at the editorial office with Meryt Zanini as the Managing Editorand Camila Sáfadi taking over the position of Editorial Manager, greatlyassisting and facilitating the work of the Chief Editor, the Associate Editors, and thereviewers. And all of them led by Professor Domingo Braile, the enthusiastic andtireless Chief Editor, whose hard work has enabled to reach this stage.Rearrangements of the journal's sessions will permit to cover articles on Innovations andNew Technologies and keep pari passu with the transformations the specialty has beenthrough.After all, several reasons make attractive to publish in BJCVS a relevant article. Ajournal with 30 years of tradition, indexed in PubMed / Medline which consequentlyallows the authors greater exposure of their paper, besides the free access on the Webto the full content of the articles and free of charge.But BJCVS still have to climb higher levels, complete the internationalization processand get to be next to the best journals in the world.


Dear authors, reviewers and readers,This editorial aims to acknowledge all of those who have contributed to our success withthe Journal of Applied Oral Science (JAOS).It is important to emphasize that the JAOS was the first journal from Latin America to beincluded in the Dentistry, Oral Surgery & Medicine category of the 2009 JournalCitation Reports (JCR) Science Edition. The JAOS has recently received its first impactfactor of 0.384, being ranked 62nd out of the 64 journals listed in this prestigious index.We are aware of the greater responsibility we will face after our inclusion in the JCR.Nevertheless, we should have a natural improvement in the JAOS's impact factor due to itsincreased exposure to the entire scientific community. The more our journal is discoveredthe greater the probability is that our journal’s articles will be cited by authorsthroughout the entire scientific community, and thus, we can achieve a greater positiveimpact worldwide.Our recent inclusions in MEDLINE/PubMed and ISI Web of Knowledge were instrumental inreaching this achievement. It is essential to remind our scientific community that thissuccess is also a result of our indexation in the Scientific Electronic Library Online(SciELO), which provides free access to the full content of all the articles published. TheSciELO network is a partnership among the State of São Paulo Research Foundation(FAPESP), the Latin America and Caribbean Center on Health Sciences Information (BIREME),and also includes many editors and national and international institutions related toscientific communication. This network must be continuously highlighted as an effectiveinstrument in exposing and internationalizing many journals indexed in this database.As we did during previous opportunities, we wish to thank all of those who supported theJAOS and provided us with invaluable contributions either as authors or reviewers. I alsowant to take this opportunity to express my gratitude to Professors Luiz Fernando Pegoraroand José Carlos Pereira, respectively former and current Dean of the Bauru School ofDentistry, for their continued support. I wish to also thank the National Council forScientific and Technological Development (CNPq), the Foundation for the Coordination ofHigher education and Graduate Training (CAPES) and the University of São Paulo fortheir financial support, which is crucial for the survival of our journal since we proudlybelong to a non-profitable public institution without ties to commercial advertisers.Additionally, it is important to recognize the superb contributions from our colleagues inthe area of Speech Language Pathology and Audiology.Finally, I will always appreciate the brave team of employees at the Bauru School ofDentistry, who support and assist me on a daily basis managing the JAOS: the librariansValéria Cristina Trindade Ferraz, José Roberto Plácido Amadei andDeborah Schmidt Capella Junqueira, the secretary Sônia Cláudia PirolaRodrigues, the journalist Neimar Vitor Pavarini, and the cover designer Rubens Kazuo Kato.I hope some day I can retribute their devotion to the JAOS, the Bauru School of Dentistryand the University of São Paulo.editorjaos@fob.usp.br  with anycriticisms, opinions or suggestions.Please do not hesitate to contact me at With my best regards,Carlos F. SantosDDS, MSc, PhD, Associate ProfessorEditor-in-ChiefJournal of Applied Oral Science


The ideal vaginoplasty method should promote good cosmetic and functional results with low morbidity. We describe a new technique for congenital vaginal agenesis using a full-thickness perforated skin graft.We report an 18 year old patient with vaginal agenesis (Morris syndrome) that undergone a modified version of McIndoe vaginoplasty.Patient is set in a low lithotomy position and lateral traction sutures are placed in labia and a 16Fr urethral catheter inserted. An inverted “V”-shaped incision is made in the mucosal plaque below the urethra. Blunt dissection in a cephalic posterior direction forms a space between the rectum and urethra. Special care is taken to avoid rectal tear during this maneuver. A full-thickness skin graft is removed from the lower abdomen measuring 12.0×6.0cm as an aesthetic abdominoplasty. The fat tissue is removed, remaining epidermis and dermis and the graft is perforated, allowing a great surface increase. After suturing over a mold, the graft is fixed in the created space. The donor site is closed with intradermal transversal suture.From January 2009 to August 2015, seven patients diagnosed with vaginal agenesis underwent this technique. There were no major complications or need for blood transfusions. At the six-month follow-up, all patients reported satisfactory sexual intercourse. There were no significant complications at donor site or neovagina that needed surgical intervention.Vaginal reconstruction using the perforated graft is viable with excellent functional results. Applying this modification, we yielded the good results of a classic McIndoe technique with lower donor site morbidity. Available at: http://www.intbrazjurol.com.br/video-section/20160259-motta_et_al/Int Braz J Urol. 2017; 43 (Video #17): 1193-1193


The cross-linked AO prototypes had composting characteristics not different from the control, indicating that the modified starch behaves the same as normal starch. The data shows the feasibility of producing all-natural bioplastic using designer starch as raw material.Bio-plastics and bio-materials are composed of natural or biomass derived polymers, offering solutions to solve immediate environmental issues. Polysaccharide-based bio-plastics represent important alternatives to conventional plastic because of their intrinsic biodegradable nature. Amylose-only (AO), an engineered barley starch with 99% amylose, was tested to produce cross-linked all-natural bioplastic using normal barley starch as a control. Glycerol was used as plasticizer and citrate cross-linking was used to improve the mechanical properties of cross-linked AO starch extrudates. Extrusion converted the control starch from A-type to Vh- and B-type crystals, showing a complete melting of the starch crystals in the raw starch granules. The cross-linked AO and control starch specimens displayed an additional wide-angle diffraction reflection. Phospholipids complexed with Vh-type single helices constituted an integrated part of the AO starch specimens. Gas permeability tests of selected starch-based prototypes demonstrated properties comparable to that of commercial Mater-Bi In March 2013, the European Commission published a green paper that outlined a strategy for decreasing the impact of plastic on the environment. The primary goal of the new strategy was to promote bio-based and biodegradable plastics [Plastics are materials composed of natural or synthetic high molecular weight polymeric molecules. These can be shaped and used in place of other materials like glass, wood, and metals. Their properties are adaptable to many applications using additives or alternative processing technologies. Bio-plastic is a sub-group that contains two qualitative characteristics: it is bio-based and/or biodegradable. The term “bio-based” refers to materials derived from biomass, whereas biodegradable refers to materials that can be assimilated by microorganisms. The main environmental threat of conventional plastics is their low degradability rates and the persistence of macro- and micro-plastics in both soil and water . Micro-p©, Novamont) due to its abundancy, low cost, and processability with the use of existing technologies.As opposed to most conventional plastics, biodegradable plastics are metabolized by environmental microorganisms, and therefore plant-based bio-plastics represent one of the most interesting clean alternative to conventional plastics. Their biochemical structure, favorable physiochemical assets, abundance in nature, and well-established fabrication technologies for plastics support development of novel bio-plastics types ,7,8,9, oStarch is heterogeneous and its composition typically entails two main polysaccharide types; amylopectin, a branched polymer, and amylose, a chiefly linear polymer. Amylose forms single and double helices that can align in ordered structures. The single helix provides a large hydrophobic cavity that can accommodate hydrophobic molecules, such as lipids ,13,14,15Polymer industry and research are increasingly pointing towards more environment-friendly solutions for plastics production. Recent investigations pinpoint opportunities of plant-based biomaterials and composites as food packaging for short- and long shelf-life products . If prodAn attractive approach is the direct modification of polysaccharides in crops using transgenic techniques. One example is amylose-only (AO) starch, produced by a transgenic barley line synthesizing a starch having 99% amylose. This starch was generated by RNA interference suppressing all three starch branching enzymes in the barley. The AO starch, as shown previously , provideThe presence of lipids complexed to amylose is expected to have a large influence on starch physics. The major internal lipids found for the AO and the control starch samples were phospholipids, especially lysophosphatidylcholine (lysoPC), as showed by TLC analysis visualized using primuline dye .AO showed a 40-fold higher free fatty acid content as compared to the control starch . These dw:w; 1:1; 1:0.5; 1:0.25). All three conditions showed exergonic transitions with increasing energy release proportional to the amount of HP catalyst used  before the extrusion, with or without sodium hypophosphite (HP) catalyst included. In the absence of a HP catalyst, no exergonic transition was detected A indicatyst used A. Subtrayst used B. The fi−1 with a spectral resolution of 8 cm−1 and attention focused to 1724 cm−1  analysis was performed with data being collected from 4000–550 cm724 cm−1 , previou724 cm−1 .The extrudates were characterized for crystallinity by wide angle X-ray scattering (WAXS), mechanical analysis, and gas permeability. After the melting process and prior to any analysis, the extrudates were stored in a controlled environment stabilizing the semi-crystalline matrix.For WAXS analysis, the extrudates were stored at 85% relative humidity (RH). The effect of both cross-linking and glycerol was evident, with both treatments increasing the crystallinity of the extrudates . PreviouThe extruded specimens, after equilibration at 57% RH, were tested by tensile tests to characterize their stress and strain behavior in standard conditions. The utilization of a double barrel extruder and controlled water feeding allowed the production of pure starch extrudates. The AO-extrudates had superior performance compared to the control starch extrudates, with AO having five-fold higher stress at break and 1.6-fold higher strain at break as compared to the control starch specimens A–C. Lack© and Low-Density Poly-Ethylene, LD-PE)  permeability. Hence, the gravimetric tests showed a significant effect of glycerol on water vapor permeability. The permeability increased by increasing the amount of glycerol in the formulation  . The permulation .This data supports the high potential behind the use of starch for the production of plastics.2 evolution . The TLC plates were assessed using a Typhoon Trio variable-mode imager . Lipid extracts from starch were analyzed using a phosphorous assay [w/v) were added to the solution. The color was developed incubating the samples in a water bath at a temperature of 80 °C for 10 min. Samples were rapidly cooled on ice water bath and the absorbance was measured at 812 nm using a GENESYS 10 spectrophotometer .The lipid extraction was performed as described by Morrison and coworkers . Butanolus assay . Shortly−1.The cross-linking reaction was performed using CA and HP as a catalyst. During the heating process (described below), the CA is converted to an acid anhydride, which reacts with the hydroxyl groups of the starch forming ester linkages. The cross-linking temperature was determined by DSC using a DSC 214 polyma  instrument. The experiments were carried out on aliquots of 20 ± 1 mg of the polymer, which was placed in stainless steel air tight cells. A single scan was performed from 30 to 140 °C by an incremental increase of temperature of 3 °C·minThe extrusion process was performed on a laboratory scale co-rotating inter-meshing twin-screw extruder . The barrel diameter and its length-to-diameter ratio (L/D) were 11 mm and 40:1, respectively. The extruder barrel was fitted with a circular 3 mm die nozzle. The extruder was powered by a 1.5 kW motor and the screw speed was kept constant at 350 rpm. The extruder had seven internal and one external heating zones and the temperature profile was optimized and set as shown in The nomenclature of the samples is indicated accordingly: starch type/plasticizer/cross-linker where the starch types were AO (amylose-only) or CT (control), the plasticizer gly (glycerol) and CA cross-linker. For example, for a plasticized cross-linked AO the nomenclature is: AOglyCA.−1 with a spectral resolution of 8 cm−1. The milled sample was squeezed against the crystal surface with a concave needle compressor. Each spectrum represents the average of 32 scans ratio against the background (64 scans measured on the surrounding air) and analysed in triplicate. Data analysis  was performed using LatentiX (v.2.12) in the range 1500–1800 cm−1.The absorbance measurements were performed on an Arid-Zone MB100 FTIR instrument  equipped with an attenuated total reflectance (ATR) device with a triple-bounce diamond crystal. IR spectra were recorded in the range from 4000–550 cmWAXS of the hydrated samples was performed using the SAXSLab instrument, NBI, University of Copenhagen, equipped with a 100XL + micro-focus sealed X-ray tube (Rigaku) with a 1.54 Å beam. The water content of the samples was adjusted by water phase sorption for 14 days in desiccators at a relative humidity of 85% (saturated KCl) .−1. The elongation and the tensile stress at break were measured at 25 °C in triplicate.Prior to any measurements, the samples were equilibrated in a desiccator at 57% ± 1 relative humidity (saturated NaBr). The specimens were analyzed using a texture analyzer  equipped with a 300 N tensile load cell. The distance between the clamps was set at 10 mm and the crosshead speed was set at 10 mm min−1 and a ramp between −60 to 150 °C. The experiments were carried out on prototypes with a length of 4 cm and an average width of 5 ± 0.1 mm.A DMA Q800  was used in cantilever mode with an amplitude of 0.1% at a frequency of 10 Hz, standard heating rate of 3 °C·minw/w) starch suspension was gelatinized using a microwave oven for 3 min in a Duran bottle closed using a membrane screw-cap to avoid over-pressure. After gelatinization, the samples were stirred for 5 min at 300 rpm and poured in the petri dishes coated with teflon, and preheated at 70 °C at a surface density of 20 mg/cm2. The suspensions were dried at 70 °C for 3 h using maximum oven ventilation and there after at 50 °C for 10 to 12 h without ventilation. CO2, O2, and H2O permeability were determined using the American Society for Testing and Materials (ASTM) Standard Method D 3985 (2010) and F1249 . Duplicate samples were conditioned for 2 days at 50% RH before the measurement. Aluminum masks were used to reduce film test area to 5 cm2. The testing was performed at 25 °C and 50% RH.Gas permeability was monitored using thin films prepared by casting. A 2%  and then every h for 8 h on the following days for at least three days (eight measurements/day).2 capture and maintenance of a moist atmosphere, a set of beakers containing 20 ml de-mineralized water and 20 mL of KOH (0.5 N) were placed on the perforated plate inside the desiccators. These were sealed and placed in a dark chamber in a climate controlled room at a temperature of 20 ± 1 °C. The desiccators were ventilated at regular intervals, and the CO2 traps were renewed on a regular basis following the standard procedure. Evolved CO2, absorbed into the KOH solutions was determined by titrating triplicates with HCl (0.5 N) to a phenolphthalein end-point.The biodegradation test was slightly modified from the ASTM standard . Large s2, O2, and H2O was comparable to commercial starch-based blends. Biodegradation in composting systems demonstrated that AO designer starch and cross-linked starch degraded at the same rate as normal starch. This new material showed that bioplastic produced using a polysaccharide from a genetically modified plant could be a functional alternative to specific flexible plastics and opens new possibilities for the production of biodegradable materials from e.g., polysaccharides, produced directly in planta, having properties specifically tailored for bioplastics applications.Massive thermoplastic polymer production is leading to an extensive accumulation of micro-plastics in the environment, and is becoming an increasing environmental threat. All-natural, biodegradable bioplastics can form part of this solution, but performance must be improved. We produced and tested extruded and CA cross-linked specimens prepared from AO barley starch. This material had superior mechanical performance as compared to specimens from normal barley starch. Cross-linking produced an additional crystal related to the A-type polymorph. CA cross-linking improved mechanical strength and the cross-linked AO extrudates had superior stress at break and elongation at break. Glycerol plasticizer decreased its performance, and despite its high elasticity, the Tg of the cross-linked AO extrudates was increased indicating the presence of a strongly cross-linked network. AO contained amylose-complexed phospholipids, with free fatty acids constituting an integrated part of the Vh crystals in the specimens. Permeability to CO


Acinetobacter sp. strain LoGeW2-3, isolated from the pellet of a white stork (Ciconia ciconia), reveals the presence of a plasmid of 179,399 bp encoding a CRISPR-Cas  system of the I-F type, and the chromosomally encoded novel class D beta-lactamase OXA-568.Whole-genome sequencing of  Acinetobacter baumannii (Acinetobacter sp. strain LoGeW2-3 from the pellet of a white stork (Ciconia ciconia) collected in Loburg, Germany, in the year 2015, following recently described protocols  did not indicate the strain’s belonging to any described species, PacBio RS single-molecule real-time (SMRT) sequencing was commissioned at GATC . Genomic DNA was isolated as recently described (N-6-methylated adenines in motifs TGAANNNNNCTG and CAGNNNNNTTCA and an unknown modification within the motif VNCGGTGTANND (modified bases underlined).While studying the ecology of the nosocomial pathogen aumannii , we isolThe plasmid encodes a CRISPR-Cas  system of the I-F type . CRISPRDTwenty putative genomic islands were predicted on the chromosome by at least one method applying IslandViewer version 4 .Acinetobacter species found in diverse environmental habitats are considered to contribute to the mobilization of antibiotic resistance genes into clinically relevant Acinetobacter species  and support our assumption that strain LoGeW2-3 is the first representative of a novel Acinetobacter species.Average nucleotide identity calculations based on BLAST+ (ANIb) analysis  indicateAcinetobacter sp. strain LoGeW2-3 has been deposited at GenBank under the accession no. CP024011 (chromosome) and CP024012 (plasmid).The complete genome sequence of


In our launch editorial on November 7, 2007, we made a statement which appears to be still applicable a decade after the journal’s inception: “Despite the wide range of more than 200 official journals in the field of surgery, there is currently no single medical journal available which specializes on the issue of patient safety in surgery.” [This year marks the 10https://link.springer.com/journal/13037), and other indexing services that are listed on the journal’s website . The journal’s overall rejection rate is 20%. The prevalent countries of origin for articles submitted and published in 2017 are depicted in Fig. “Complications in colorectal surgery: risk factors and preventive strategies” [In the past decade, the journal published a total of 325 open-access articles, all of which are cited in PubMed, SpringerLink (“Why do surgeons continue to perform unnecessary surgery?” [Another important aspect related to the journal’s global visibility is reflected by the so-called “Altmetric Attention Score”. This represents an emerging tool designed to assess the public attention that scholarly articles receive through the media, news outlets, blogs, and social media. The score is influenced by the quantity of posts that mention an article and by the quality of the source of posting. Of note, Altmetric measures public attention, not scientific quality. The PSS article with the highest Altmetric Attention Score of all times was a 2017 editorial entitled urgery?” . Impressurgery?” . These sIn spite of these impressive metrics, which are reflective of a successful development and increased visibility of the journal since its inception in 2007, there is much work to be done. Notwithstanding significant developments in medical care and technology, the “modern age” of patient safety in the twenty-first century continues to fall short of protecting patients from unnecessary treatment, preventable harm, and death. Shockingly, current statistics have identified medical errors as the 3rd leading cause of death in the United States, secondary only to cardiovascular disease and cancer . The hid


Publishing and successfully running a good quality peer reviewed biomedical scientific journal is not an easy task. Some of the pre-requisites include a competent experienced editor supported by a team. Long term sustainability of a journal will depend on good quality manuscripts, active editorial board, good quality of reviewers, workable business model to ensure financial support, increased visibility which will ensure increased submissions, indexation in various important databases, online availability and easy to use website. This manuscript outlines the logistics and technical issues which need to be resolved before starting a new journal and ensuring sustainability of a good quality peer reviewed journal. A Journal is only as good as its Editorial Team and the quality of its reviewers. Hence for the successful running of a journal the first and the foremost important pre-requisite is a competent editor supported by a team of editorial staff. In fact, there are some bare minimum requirements which are essential for running a successful journal and ensure its sustainability in the long run. These are as under:Good quality manuscriptsProper office and Minimum essential staffFinancial sustainabilityActive Editorial BoardGood Quality of ReviewersIncreased visibilityIndexation in various databasesOnline availabilityEasy to use WebsiteAfter having completed the legal requirements and governmental formalities of obtaining a declaration, one should first assess the strength and resources because everything which follows will depend on that. It is always important to move slowly and ensure steady progress. Decide about the frequency of your journal/publication which could be annual, biannual, quarterly, bimonthly or monthly. Be careful in selecting the members of the editorial board and founder members. Do not go for the big names that are too busy and do not have time but instead select those who are keen and interested. Decision about the frequency of publication will be determined keeping in view the financial resources. Of course timely publication as per frequency is extremely important.When starting a new journal, there are some logistic and technical issues which have to be resolved. First of all it is essential that there should be a proper office with minimum full time staff. This also includes better title, designing a website with good impact, deciding about some manuscript management system, applying for ISSN number and in case of both print and online versions; one will need separate ISSN numbers for both. Decide about the Abbreviation of the Journal which should appear everywhere and which will be used while writing references.2Decision about Peer Review system which one has to be followed i.e. single blind, double blind or Open Peer Review System. It may take some time to develop a good Reviewers Database for the journal and it is up to the Editorial team to ensure to grow and retain good reviewers.4The well known functions of the media, print or electronic are to inform, educate and guide. Hence the contents of a scientific journal can reflect most of the above functions. One can include stories and manuscripts which have useful information for the readers of the journal. Secondly the journal can serve as a useful medium to educate the general public or its intended readership on various issues of national importance keeping in view the local socio economic development, environment and cultural values. To do this it is important that the writer is intelligent and competent enough to educate the readership after having compiled all the essential information. In this the writer/contributor is required to interpret the events, happenings and highlight their likely effects or repercussions. The third and the most important function is guide which cannot be accomplished unless the writer has kept himself/herself informed, fully abreast of the latest developments on the subject he or she is writing. An ignorant author is no less than a weapon of mass destruction because instead of guiding the readers, he or she can misguide the public and the readers at large. In order to ensure that no wrong messages is communicated, the concept of peer review was coined many years ago whereby the write-ups before publication are looked into by experienced, competent individuals in the respective field apart from the Editor. It is the job of the Editor to arrange and organize an effective peer review system for the journal. While peer review has its own advantages it also has some disadvantages as it can slow down the pace of work, can result in delay in publications and at times even may not be able to detect any wrong information or scientific, academic misconduct.The journal must have a wide variety of contents to satisfy the needs of every class and group of readers. Starting from original research, the contents can include Reviews, Clinical Case Series, Short/Brief Communications, short stories, important news, Book Reviews, Obituary Notes, Quiz etc., while comments from the readers should be encouraged and welcomed. Conference Reports could be quite useful and informative for many who for some reasons cannot attend these meetings. Information about the forthcoming important events, conferences, seminars, symposia could also be very useful addition and informative for the readers.A good review should help the authors to revise and improve the quality of their manuscript. Committee on Publication Ethics (COPE) has prepared some Flowcharts which provide useful guidelines to the editors to handle scientific misconduct.5SIMRAD whereinInternational Committee of Medical Journal Editors (ICMJE) has formulated some guidelines for submission of manuscripts to biomedical journals which are revised after every couple of years.S stands for structured abstract.I stand for IntroductionM stands for MethodsA stands for analysisD stands for Discussion.The manuscript is then followed by conclusions, acknowledgements and the relevant references. Authors are required to declare their conflict of interest and the source of Funding if any. Structured abstract usually contains four sub-headings i.e. Objective, Methods, Results and Conclusion followed by relevant Key Words. For Case Reports, Special Communications a one paragraph Summary is considered enough. However, while writing a Review Article, the International Committee of Medical Journal Editors (ICMJE) guidelines require that the summary must also provide information about the Data Bases which were used for literature search and the time period, how the information was extracted.6For Journals/publications covering Culture and Sociology, it is important that they include manuscripts which carry some message relevant in these fields. Success stories which could encourage others to follow the same footsteps could be a useful addition to the contents. Real life events which have some message how to tackle some particular problems would be welcomed by the readers. Contents should be such that it invites the readers and when the readership increases, it is considered a very healthy sign for the publication.The print issue as well as the journal website must contain comprehensive information for the authors. It should give details about the maximum number of words which the journal will accept in different categories of write-ups, maximum number of figures and tables to be included. It should provide comprehensive guidelines to the authors including journal policy regarding plagiarism.Details about processing fee if any, publication charges, peer review system, types of manuscripts accepted for publication, details about fast track processing of manuscripts, Registration of trials, pharma industry sponsored studies, likely time period from submission to peer review etc., must be clearly mentioned in the instructions ensuring transparency. There should be no hidden charges. It is also advisable that the journal provide some forum for redress of grievances, complaints to the authors, readers, reviewers, advertisers. Those whose manuscripts are rejected should also have a chance to appeal against the decision. These days some journals have appointed Ombudsman for this and their contact details are published in the journal as well as on the journal website.Sometimes the manuscript received for publication need improvement of English language and Grammar. If the journals can afford, they should appoint Copy Editors. They are supposed to not only improve the English language and Grammar but also eliminate repetition of information, redrawing the tables and figures if need be so that the message is conveyed effectively. However, if there is no copy editor in the staff, this has to be done by the Editor. Some software’s i.e. Grammarly.org are also available for improvement of English language and Grammar but one has to subscribe it.7While print version of the journal has its importance as seeing is believing, but it is expensive and takes time. On the other hand, Online Edition of the Journal is not only highly economical but it is also very quick. Hence it is essential that a journal/publication should have both versions, print format as well as the Online Edition which will increase the visibility of the publication manifold.It is one of the most important aspects and the Editor should ensure adequate funding to sustain the long term publication. The sources of funding could be through donations, grants from philanthropists, Trusts or Foundations, Government Grants if possible. Subscription generation takes time and even then it does not fetch much funding for sustained growth. However, an important source of income could be through advertisements for which one needs a strong committed business team. Initial few years could be very taxing but as the time passes and the journal/publication earns some credibility, readership and improved visibility, things start becoming a bit easier. Once the Journal gets established, “Authors Pay Business Model” ensures financial sustainability. However, even then there are too many problems which one has to face. It must be remembered that running and managing a good quality peer reviewed journal in any subject, specialty particularly in the Developing world is a very frustrating and stressful job because of financial constraints and lack of trained, experienced human resource. While training the staff will take time but how to retain them once they have been trained is yet another uphill task for the management.9Recognition by the regulatory agencies for example in case of Pakistan by Pakistan Medical & Dental Council (PM&DC) and Higher Education Commission (HEC) of Pakistan will ensure more submissions. Sometimes HEC also provide some financial grants to the journals but the journals have to provide the audited accounts of this grant at the end of the year.https://clarivate.com/) and getting Impact Factor, applying for DOI numbers after contract with CrossRef all ensure credibility, increased visibility and readership which in turn results in increased submissions. However, all this may not be easy as most of these databases have Evaluation Committees to look at the quality of contents before accepting to recognize the journal. Moreover, timely regular publication is a pre-requisite.10Recognition and coverage in Directory of Open Access Journals (DOAJ), inclusion in Medline PubMed, PubMed Central, Scopus, recognition by Thompson Reuter (Clarivate Analytics (A number of free software’s are available on the net to check plagiarism but the most important one is Turnitin/iThenticate which one has to subscribe.7The problems and difficulties related to running a successful journal are also related to the ownership of these publications. If the Society, Organization, Foundation or Trust or the institutions including Universities are the owners, they can set aside enough funding for this project. Not only that, they can even acquire the services of trained and experienced people to run and manage the journal. However, while assuring financial support, these institutions, organizations must also ensure that the Editor has enough independence to take day to day decisions related to the journal which are extremely important. But if the Editor has to take permission for each and every action, decision, from the higher authorities, it will not only slow down the whole publication process but never encourage the Editorial team to take initiative. Ideally the editors should have a contract appointment wherein their tenure, rights and responsibilities should be clearly stated.During the past two decades, there have been tremendous developments in Information technology which on one hand has made the job of Editors easy but at the same time, it has also put them under lot of stress and it has become quite difficult for the Editors to come upto the expectations of authors who are quiet impatient, wish to see their manuscripts in print as soon as possible. They are also known to be the most dangerous pressure groups, which the editors have to face.12In conclusion, running and managing a good quality journal faced with financial and human resource constraints is not easy. It is quite frustrating and stressful job and all these problems, difficulties which one can encounter must be looked into before embarking on this journey of publishing a Journal. However, professional competencies of the Editor will ensure smooth sailing to a great extent.13


The microstructure, phase composition, tetragonal to monoclinic transformation behavior and mechanical properties were investigated and are here discussed as a function of the ZrO2 content. The material containing 10 vol % ZrO2 presented a relevant hardness and exhibited the maximum value of I0K, mainly imputable to the t → m transformation at the crack tip.Alumina-zirconia (AZ) composites are attractive structural materials, which combine the high hardness and Young’s modulus of the alumina matrix with additional toughening effects, due to the zirconia dispersion. In this study, AZ composites containing different amounts of zirconia (in the range 5–20 vol %) were prepared by a wet chemical method, consisting on the surface coating of alumina powders by mixing them with zirconium salt aqueous solutions. After spray-drying, powders were calcined at 600 °C for 1 h. Green bodies were then prepared by two methods: uniaxial pressing of spray-dried granules and slip casting of slurries, obtained by re-dispersing the spray dried granulates. After pressureless sintering at 1500 °C for 1 h, the slip cast samples gave rise to fully dense materials, characterized by a quite homogeneous distribution of ZrO Zirconia toughened alumina (ZTA) is one of the most widely used composite oxide structural ceramics. In fact, for several years, ZTA composites have been used for wear parts and cutting tools, due to their excellent mechanical properties, such as high strength, hardness, toughness and abrasion resistance ,2,3. MorIn this frame, ZTA composites have demonstrated their effectiveness for orthopedic applications, and recently, the first composite femoral heads have been developed and commercialized. In this system, alumina provides high strength and hardness, whereas tetragonal zirconia exerts a toughening effect, thanks to its controlled transformation into the monoclinic phase ,6. In spGenerally, ZTA composites are prepared by the powder mixing route, whose main issue is keeping a homogeneous microstructure in the final, sintered materials. In fact, zirconia aggregates can lead to localized aging phenomena ,10, wherThis work deals with the elaboration of ZTA composites through a simple and reliable method, which allows an effective tailoring of the powder characteristics, microstructure and properties of the fired bodies, as already demonstrated for other bi- ,12,13,14AZ green bars, prepared by uniaxial pressing of the spray-dried powders, presented green densities in the range 48%–52% with respect to the theoretical density (TD), as shown in By environmental scanning electron microscopy (ESEM) observation, residual pores were detected, in agreement with the density values. In addition, as shown in 50) of the ball-milled slurry was about 0.17 μm, one order of magnitude lower than the d50 of the powder before milling and comparable with the alumina primary particle size. Similar results were obtained for suspensions with higher solid loadings, but the time required for dispersion increased by increasing it. In fact, the slurries whose solid loading was 60 and 70 wt % reached a particle size distribution similar to that of The reliability of fired materials was thus improved by slip casting, as reported in the following, which was performed with the aim of increasing the microstructural homogeneity in green and sintered bodies. All AZ aqueous suspensions were successfully dispersed by ball-milling: as an example, Y) and viscosity limit (ηY) of the same suspensions are collected in Thus, in order to reach the best compromise between high solid loading and low viscosity, AZ suspensions at 60 wt % were dispersed and cast. The slip cast green bodies were then sintered in the same conditions used for the pressed materials. The green and final density of the slip cast samples are collected in 2 content, is collected in 2 content in the composites. On the opposite, the alumina grain size is inversely proportional to the zirconia content: the well-known pinning effect exerted by zirconia on the alumina grain size was effective in limiting the matrix grain growth, as already stated in the literature. For instance, Lange [2 inclusions, thus avoiding alumina abnormal grain growth.Image analysis, carried out on several ESEM micrographs, allowed to evaluate the alumina and zirconia size distribution. Their mean size, as a function of the ZrOe, Lange  reportedmp) and fracture (Vmf) surfaces [mp being quite low for AZ5 and AZ10 samples , it significantly increased in the ZrO2-reacher compositions.surfaces . In spit2O3 is characterized by an elastic modulus, which is quite double that of ZrO2 [et al. [CD, above which spontaneous transformation can occur during cooling from sintering to room temperature.The conditions under which the tetragonal zirconia phase can be retained at low temperature have been the object of numerous papers, dealing with the thermodynamics of the t → m transformation in different systems, including ZTA composites ,22,23,24 of ZrO2 , its sti of ZrO2 , zirconi [et al. . FinallyCD was evaluated by combining the cumulative size distribution of zirconia, shown in In this work, 2 transformability played by the matrix constrain and residual stresses. In fact, the matrix constrain, which counteracts the t → m transformation, decreases by increasing the zirconia content. On the opposite, the tensile residual stresses, which promote the transformation, are more effective in alumina-richer compositions, as shown by Becher et al. [2), the influence of the residual stress prevails, so that the CD value obtained for AZ10 is greater than the AZ5 one. From 15 vol % ZrO2, the decreased influence of the matrix stiffness causes an increase in the zirconia transformability, and thus, CD decreases again.It can be observed that AZ10 critical size was larger than those of all other composites. For explaining this behavior, we should consider the opposite effects on the t-ZrOr et al. . Accordimf also increased by increasing the zirconia content. The zirconia transformability, determined as the difference between Vmf and Vmp, is depicted in the same Figure, showing a maximum value for AZ10. In order to deepen the dependence of the stress-induced transformation on the zirconia grain size, the lower critical size under which such transformation does not occur, ICD, was also evaluated. By following the same previous approach, ICD was estimated by coupling the Vmf data with the cumulative volume distribution of ZrO2 in the AZ composites, depicted in 2 amount available for stress-induced transformation is reached when its dimension is in the range ICD–CD. The slightly larger ICD–CD range determined for AZ10 can explain its higher transformability, as compared to the other composites.As shown in HV10) as a function of the zirconia volume content. In spite of the decreased alumina grain size in the ZrO2-reacher composites, the hardness decreased from AZ5 to AZ20, as expected on the grounds of the rule of mixture [I0K, as a function of the zirconia content, showing a maximum for AZ10. This result is in agreement with previous literature data: in fact, a maximum is frequently observed in CK as a function of the zirconia content [2 concentration for which a substantial increase in monoclinic content is observed after sintering, in agreement with data shown in  mixture . The len content ,9 in ZTAI0K values, which are in good agreement with literature data [i.e., microcracking and stress-induced t → m transformation. Microcracking is possible when the size of the ZrO2 inclusion exceeds a critical size (sD), which can be calculated according to the following Equation [The obtained ure data ,28, can Equation :(1)Ds=1m is the fracture energy for microcracking (~1 J/m2), E the elastic modulus of the composite  and Δε = Δα·ΔT the product of Coefficient of Thermal Expansion (CTE) and sintering temperature difference [2 particles size in all the investigated AZ composites. Thus, a contribution to toughness from microcracking due to large, transformed zirconia particles was not expected. So, the higher (and similar) I0K values determined for AZ10 and AZ15 can be explained taking into account their higher zirconia transformability  composite powders were prepared starting from commercial α-alumina powders . Well dispersed alumina suspensions were mixed with aqueous solutions of zirconium chloride. The doped slurries were maintained under magnetic stirring for 2 h and then spray dried. The powder was calcined at 600 °C for 1 h, to decompose by-products (mainly chlorides) and to induce the crystallization of tetragonal zirconia on the alumina surface. The elaboration method of the composite powders have been widely described in some previous papers [2; samples are hereafter referred to as AZ5, AZ10, AZ15 and AZ20, respectively. The volume percentage of zirconia into the composite powders was calculated assuming that it was fully tetragonal (6.05 g/cm3) in the final composites.Alumina-ZrOs papers ,14. The −1 in 2 min; the suspension was kept at the maximum shear rate for 1 min and then decreased to 0 once again in 2 min. The shear stress (τ) was thus measured according to the Casson equation [Y is the yield stress and η∞ is the viscosity limit for infinite shear rate.Green bodies were prepared by using two forming technologies. In the first case, the spray-dried granulates, calcined at 600 °C, were uniaxially pressed at 150 MPa. In the other, aqueous slurries, with solid loading ranging between 50 and 70 wt % were first dispersed by ball-milling, by using 3Y-TZP spheres. The particle size evolution, as a function of the dispersion time, was followed by laser granulometer . The rheological behavior of each suspension was also investigated by using a Coulette rheometer , at the following conditions: the shear rate (γ) was increased from 0 to 1500 sequation :(2)τ1/2After that, the dispersed slurries were de-aired under vacuum for a few minutes and then cast into pure alumina porous molds and dried in controlled humidity atmosphere for 48 h. The samples were de-molded and left in static air for an additional 24 h.The green bodies were submitted to dilatometric analysis, under the following sintering cycle : heating3 for α-Al2O3 and tetragonal ZrO2, respectively. Sintered samples were submitted to X-ray diffraction (XRD) by using a Philips PW 1710 apparatus, operating with Cu Ka radiation ; spectra were acquired in the range 5°–70° 2θ, with a step size of 0.05° 2θ and an acquisition time per step of 5 s. Diffraction patterns were indexed by using the Powder Data File database . XRD were carried out on both polished and fractured surfaces; the intensities of the monoclinic (−111) and (111) reflexes, as well as the tetragonal (101) reflex were integrated, and the volumetric content of the monoclinic phase was calculated with the calibration curve of Toraya et al. [The as-sintered samples were submitted to density measurements using the Archimedes’ method. The theoretical density (TD) was calculated for each composition, assuming values of 3.98 and 6.05 g/cma et al. .The microstructural characterization of the sintered bodies was carried out by environmental scanning electron microscopy  on polished and thermally etched surfaces, as well as on untreated fractured ones. Polishing was performed down to 1 μm with a diamond paste, whereas thermal etching was carried out at 100 °C below the sintering temperature, for 6 min.P is the applied load, c is the crack length measured from the center of indentation to the end of the crack and χ is a constant equal to:ζ being a material-independent constant, equal to 0.016, E the Young modulus and H the hardness. The Young modulus of the composites was evaluated by the rule of mixtures, assuming values of 400 GPa and 200 GPa for alumina and zirconia, respectively [The Vickers hardness was determined on all the samples by applying a maximum load of 98.1 N, by using a micro-indenter Vickers Testwell FV-700, equipped with an optical microscope. For each indentation, the length of the two diagonals was measured, and the corresponding hardness was determined according to standard equations . The mea2 particles inside the alumina matrix. The four composite materials have been compared in terms of different microstructural features, phase composition and mechanical properties. The composite containing 10 vol % ZrO2 exhibited good hardness and the maximum fracture threshold, I0K, which was mainly imputed to the t → m transformation at the crack tip.In this work, Alumina-Zirconia composite powders have been successfully produced by surface modification of a commercial alumina with aqueous solutions of zirconium chloride. This method allowed us to produce composite powders with the desired alumina-zirconia ratio, as well as with strictly tailored microstructural features, such as zirconia grain size and distribution. Composite powders with four different compositions were prepared, containing respectively 5, 10, 15 and 20 vol % of un-stabilized zirconia. Green bodies were prepared by two forming techniques, uniaxial pressing and slip casting. The second route was very effective in producing homogeneous and defect-free green bodies, which gave rise, after sintering at 1500 °C for 1 h, to fully dense microstructures, characterized by highly homogeneous distribution of ZrO


The Brazilian Journal of Cardiovascular Surgery (BJCVS) is grateful for the reviewers,listed below, which collaborated in this edition. Without their work would be impossibleto keep the high scientific standard of our journal.Alexandre HuebDouglas BolzanEduardo K. SaadiFernando PlataniaGabriel LiguoriGibran FeguriJoão Carlos Ferreira LealJoão de Deus e BritoJosé Carlos M. PachonJose Dario Frota FilhoKarlos VilarinhoLindemberg SilveiraLuciano AlbuquerqueLuís DallanMagaly Arrais dos SantosMarcos Aurelio Barboza de OliveiraMichel Pompeu B. de O. SáMilton SantoroPaulo Roberto EvoraPedro SalernoRenato ArnoniRicardo Carvalho LimaRodrigo MilaniStevan Martins


In attendance were President Laura Landweber, Past-President George Zhang, President-Elect Bill Martin, Councilors Emma Teeling, Kateryna Makova, Maud Tenaillon, Adam Eyre-Walker, Joanna Masel, Jay Storz, Secretary David Pollock, Treasurer Juliette de Meaux, and MBE Editor-in-Chief Sudhir Kumar (Cathy Kennedy. Claus Wilke (Austin—SMBE2017), Koichiro Tamura (Yokohama—SMBE2018), Yoko Satta (Yokohama—SMBE2018), James McInerney (Manchester—SMBE2019) attended part of the meeting, an Oxford University Press delegation consisting of Alex Beaumont and Adam Leary attended part of the meeting, and Terry Leatherman (Allen Press) attended part of the meeting.The council approved the minutes of the 2016 Council and Business meeting, published in the January 2017 issue of MBE .Treasurer Juliette de Meaux summarized the financial state of the Society, with details on journal and meeting revenue and expenses. The records show that the Society is in excellent financial health, with total net assets of US $3, 517, 858. More details can be found in the Treasurer’s report.Secretary David Pollock reviewed the council actions over the preceding year. Central issues were interactions and contracts with MBE and GBE publisher OUP, Allen Press, and MCI, as well as the upcoming GBE Editor-in-Chief replacement and diversity issues in a number of areas; details are summarized below.ex officio, as per by-laws. The membership of the society was informed by email of the committee composition in early 2017 and was asked to nominate candidates for the various positions.The nominations committee for nominating candidates for the position of President-elect, for Treasurer, and for two council positions was chaired by Wen-Hsiung Li (Chicago). The members of the committee were Ruth Hershberg , Marc Robinson-Rechavi , Beth Shapiro (Santa Cruz), Gunter Wagner , and David Pollock SMBE Secretary, (Denver), The nominees for President-elect were Anne Stone (Arizona State University) and Aoife McLysaght . The nominees for Treasurer were Jeff Thorne (North Carolina State University) and Michael Rosenberg (Arizona State University).The nominees for the councilor positions were Belinda Chang , Keith Crandall (George Washington University), Nicholas Galtier , and Anthony Poole .The membership of the society was issued online ballot details through Allen Press with the voting period open from April 21 to June 1, 2017. The results of the ballot are that the President-elect is Aoife McLysaght, the Treasurer is Jeff Thorne and the newly elected councilors are Belinda Chang and Nicholas Galtier.The council does and will continue to remind the nominating committee every year of gender and geographic diversity goals, but maintains flexibility in how this is achieved by the committee.The Editors in Chief of MBE and GBE gave reports on the current state of their journals (see separate editors’ reports). There is a healthy submission rate for both journals, with respective acceptance rates of 25% and 50%, and both journals are working to improve or maintain gender and geographic balance on the editorial boards. OUP also gave a presentation on their work on the journals and transition to a new online publishing system.The next annual meeting of the society will be held from July 8–12 in the Pacifico Yokohama, Yokohama, Japan. The 2019 meeting will be held in Manchester, United Kingdom, and by vote it was decided that the 2020 Annual meeting will be held in Quebec City, Canada.Councilor Kateryna Makova organized review of satellite meeting proposals and councilor Maud Tenaillon organized review of interdisciplinary meeting proposals. It was voted to fund proposed interdisciplinary  meetings in Lyon, France (“Interdisciplinary approach for molecular evolution”), Cali, Colombia (“Colombian association for evolutionary biology”), and Pittsburgh, Pennsylvania (“Three Rivers Evolution Event”). It was voted to fund satellite meetings in Utah (“Molecular evolution and the cell”), India , Rhode Island (“Modern methods for the study of ancient DNA”), Japan (“Genome evolution in pathogen transmission and disease”), and Italy (“Evolution of genome architecture”). It was also voted to fund a special symposium in Pennsylvania (“Molecular evolutionary genetics”) to honor one of SMBE’s founders, Masatoshi Nei.Councilor Joanna Masel organized the undergraduate mentoring and diversity program at the annual meeting. This program was able to make 11 awards. By acclamation of the council, it was decided that in the future, senior faculty can also be mentors.This award is given to outstanding members of the SMBE community who are in the early stages of an independent research career. The 2017 recipient was Mia Levine (University of Pennsylvania).This award is intended for outstanding members of the SMBE community who are in the midst of their research careers. The 2017 recipient was Toni Gabaldón, .This award is intended for outstanding senior members of the SMBE community. The 2017 recipient was W. Ford Doolittle .This award is intended for members of SMBE who have provided exceptional service to SMBE and the broader scientific community. The 2017 recipient was Sudhir Kumar (Temple University).President-elect Bill Martin ran the award process with 24 people assisting. There were about 800 posters, including about 350 undergraduates, 200 postdoctoral researchers, and 29 undergraduate students. Motions passed unanimously to allow up to 9 poster awards at discretion of organizers, and increase award to $500 at all three levels. The 2017 postdoctoral best poster awards went to Marc Tollis (Arizona State University), Elizabeth Atkinson (Stony Brook University), and Atahualpa Castillo Morales . The best poster for graduate students went to James Fleming , Pinglin Cao , and Magdalena Kubiak . The best poster for undergraduate students went to Isabela Jeronimo Bezerra Marcos , Joseph Palmer , and Dan Werndly .Past-president George Zhang organized the Fitch speaker and travel award judging with a committee of five councilors. 358 people applied for some combination of the Fitch Prize, travel and registration awards, and there were 8 Fitch finalists, 52 travel awards, and 93 registration awards. The Fitch Prize winner was Anna Vickrey (University of Utah) for a talk titled “Domestic pigeon’s checkered past: wing color pattern variation is associated with one gene, two mechanisms, and interspecific introgression”.The MBE best paper award was given to Alejandra Rodríguez-Verdugo  for the paper “First-step mutations during adaptation restore the expression of hundreds of genes”, and the GBE best paper award was given to Anouk Willemsen  for the paper “Predicting the stability of homologous gene duplications in a plant RNA virus”.There were 33 childcare awards provided, in addition to on-site childcare, with children ranging from 1 month to 11 years old.The council unanimously approved that, if funds are available when an editor-in-chief of a successful SMBE journal steps down, we will, in principle, provide US $75, 000 per full term served as editor-in-chief to support the research program of the former editor-in-chief. This amount may be adjusted for inflation or for circumstances such as starting a new successful journal. Term limits for editors in chief were discussed but not implemented at this time, although this issue may be revisited in the near future.It was determined that the Sexual Harassment Policy approved for the Austin meeting should be kept as permanent policy.The council made progress in negotiating a contract renewal with Allen Press for web and email services, and a multi-year contract with MCI for meeting organization services.It was unanimously agreed that SMBE would share gender statistics of SMBE members, as requested by Nicolas Rode, but only the total numbers. Councilor Maud Tenaillon gave a presentation on estimated gender and career stage distributions at recent SMBE meetings (separate publication).Peer Community In Evolutionary Biology (PCI Evol Biol), and partly due to the ambiguity of their “peer-reviewed” status, it was decided that they should not use the SMBE logo and SMBE will not be providing support at this time, although we wish them good luck in their efforts.The idea of a new journal was discussed and it was determined that there is no need to start a new journal at this time. It was also discussed whether SMBE should support the new-style journal President Laura Landweber called the council meeting to order at 12 PM on July 4.The president summarized the discussion at the council meetings, announced the location of the 2018, 2019, and 2020 meetings, announced the outcomes of the elections and congratulated the organizers of the Austin meeting. Koichiro Tamura gave a short presentation on the logistics of the 2018 annual meeting in Yokohama, Japan.


To understand whether the increased outpatient service provision (OSP) brings in enough additional income  for primary hospitals (INCOME) to compensate for reduced costs of medicine.The two outcomes, annual OSP and INCOME for the period of 2008–2012, were collected from 34,506 primary hospitals in 2,675 counties in 31 provinces in China by the national surveillance system. The data had a four-level hierarchical structure; time points were nested within primary hospital, hospitals within county, and counties within province. We fitted bivariate five-level random effects regression models to examine correlations between OSP and INCOME in terms of their mean values and dose-response effects of the essential medicine policy (EMP). We adjusted for the effects of time period and selected hospital resources.The estimated correlation coefficients between the two outcomes’ mean values were strongly positive among provinces (r = 0.910), moderately positive among counties (r = 0.380), and none among hospitals (r = 0.002) and time (r = 0.007). The correlation between their policy effects was weakly positive among provinces (r = 0.234), but none at the county and hospital levels. However, there were markedly negative correlation coefficients between the mean and policy effects at -0.328 for OSP and -0.541 for INCOME at the hospital level.There was no evidence to suggest an association between the two outcomes in terms of their mean values and dose-response effects of EMP at the hospital level. This indicated that increased OSP did not bring enough additional INCOME. Sustainable mechanisms to compensate primary hospitals are needed. In response to allegations that it is too difficult and too expensive for many Chinese people to seek health care, China’s central government launched a new round of national healthcare reform in April 2009. The main goals of this reform included accelerating the construction of the basic medical security system, establishing national essential medicine policy (EMP), improving the primary medical and health service system, promoting the equality of basic public health services and promoting government-run hospitals reform . The EMPNumerous studies have shown some positive effects of the policy, such as the increased service usage due to reduced costs of medicine –9, reducOne of the main effects of EMP was to reduce the cost of medicines. This would certainly weaken the hospitals’ financial situations , 18–20; NHRMSS was a national survey that was conducted among all healthcare-related facilities every year from 2008–2012 in all of China to acquire the basic information about facilities for the new healthcare reform. The survey was conducted by the Center for Health Information and Statistics, National Health and Family Planning Commission of China . The surSix hospital-level measures are: (1) time exposed to policy of hospital in year (TETP) ranged from 0 to 4 years, (2) location  and hospital type, (3) quantity of staff, (4) quantity of health technical personnel, (5) quantity of bed space, and (6) total assets. These variables showed the basic features of the hospital in terms of staff, assets and equipment, and properly reflected the characteristics of the hospital. Dividing measures (4) and (5) by measure (3), we obtained two new variables: health technical personnel ratio (HTPR) and bed space ratio (BSR), respectively, to measure relative quality of human resource and relative treatment bed space. In addition, dividing measure (6) by measure (3), the logarithm transformed into the new variable, total asset ratio (LTAR), to reflect a relative capacity in medical tests or diagnosis.Two main outcomes at the hospital level are: (1) number of outpatient service provision (OSP) and (2) total income, excluding income from essential medicine (INCOME). INCOME was adjusted by the nation’s CPI in each year against that in 2012, and logarithm transformation was performed on both OSP and INCOME due to their skewed distributions.We were interested in four questions. Firstly, were OSP and INCOME correlated overall, and if so, in what direction? Secondly, were there dose-response effects (or change trends) of the EMP for OSP and INCOME overall? If so, it could demonstrate the general intensity and sustainability of the EMP. Thirdly, would the correlations and the dose-response effects remaining after adjusting for covariates? Fourthly, were OSP and INCOME correlated in terms of their mean values and dose-response effects of the EMP at corresponding levels, respectively? This could remind us whether the two outcomes followed the same trend as the EMP.Based on the data structure, previous research had applied four-level repeated measures models to assess dose-response effects of the EMP policy for single outcome, such as OSP . For corWe fitted a bivariate, five-level null model to obtain the raw correlation relationship between OSP and INCOME at different levels of the data structure without adjusting other influential factors. Specific definitions for the hierarchy included:Level 5: provinces, denoted by m;Level 4: counties, denoted by l;Level 3: hospitals, denoted by k;Level 2: time, denoted by j;Level 1: indicator to define the bivariate structure, denoted by r;respjklm1, respjklm2 stood for OSP and INCOME respectively; while β0, β1 were the regression coefficients of constant item const  for the two outcomes. Meanwhile, gm0, flm0, vklm0, and ujklm0 were residual of const at levels five, four, three and two for OSP, and the same for INCOME. β0 and β1 were the mean values of OSP and INCOME, and they were the fixed coefficients of the model.Details of the model were introduced as following:g, Ωf, Ωv and Ωu were variance and covariance matrices for residuals of units at levels five, four, three and two respectively. Following the definition of Pearson’s correlation, elements in these matrices could be used to calculate correlation relationships between OSP and INCOME at corresponding levels, and they were the random coefficients of the model.In addition, ΩThe estimate of fixed and random parameters was presented in The Pearson’s correlation coefficient between the two outcomes was calculated based on the estimated variance-covariance in σg01, σf01, σv01, σu01) at the four levels jointly using a generalized Wald test, we obtained χ2 test statistic with with P values as less than 0.000, less than 0.000, 0.046 and less than 0.000 respectively, as shown in the last column in Based on the model estimates we obtained a strong positive association between mean values of OSP and INCOME among 31 provinces, moderately positive among 2,675 counties, and weak among 34,506 facilities and time points. Testing the significance of the covariance between the two outcomes , into the null model to identify the raw dose-response effects of the EMP. The fixed part of the model was as follows, and the estimated values are presented in P values both less than 0.000, demonstrating both increased OSP and INCOME as the exposure time to the EMP policy increased. The inclusion of the TETP variable reduced the -2*log likelihood from 691297.7 down to 624794.3 to give a much improved model showing significant effects of the dose-response trends. Meanwhile, the correlations between the two outcomes had no obvious changes.The results showed that dose-effects of EMP for OSP and INCOME were positive and significant, with X stood for the other explanatory variables, and βx were their regression coefficients.We introduced other explanatory variables—year (comparing to year 2008), HTPR, LTAR, hospital type (comparing to CHC), region (comparing to East), the first order interaction between TETP and hospital type, and the first order interaction between TETP and region—into the model to adjust the confounders, and then we identified the correlation relationship between OSP and INCOME at different levels and the true dose-response effects of the EMP. The estimated values are presented in P values of the χ2 test statistic for the covariance at each of the four levels being less than 0.000, less than 0.000, 0.617, and less than 0.000 respectively. It suggested that the two outcomes’ correlation at province and county levels still had statistical significance. However, the regression coefficient of TETP for INCOME became negative (-0.052), while that of OSP was still positive (0.044). The negative effect could suggested that longer exposure time to the EMP policy could be associated with a decreased INCOME, and the positive one could suggested that a longer exposure to the EMP may trigger an increased outpatient services in general. These directions of changes fitted the objectives of the EMP policy. Besides, after including time period and hospital resources, the -2*log likelihood declined to 580308.2 from the dose-response model’s value of 624794.3, suggesting that this was a much improved model.After adjusting for the confounders, the estimated correlation coefficients between the mean values of OSP and INCOME were 0.906, 0.398, 0.002, and 0.014 at the four levels, with At last, we fitted a random coefficients model for TETP. The model was as follows, and the results are presented in β2, gm2, flm2 and vklm2 were the fixed parameter, residuals of TETP at level five unit, four unit, and three unit respectively for the dependent variable OSP. Similarly the corresponding terms for the dependent variable INCOME were β3, gm3, flm3 and vklm3. The terms β2 and β3 were the mean values of TETP for dependent variables OSP and INCOME.The terms g, Ωf, Ωv and Ωu were variance and covariance matrices for residual of const and TETP at level five unit, four unit, three unit and residual of const at level two unit, respectively. They reflected the correlation relationship between OSP and INCOME in terms of their mean values and dose-response effects of the EMP at corresponding levels. For example, the correlation between the two outcomes in term of their dose-response effects at the province level was calculated by σg23, In addition, ΩBased on the model estimates, the correlation coefficients of random intercepts between the two outcomes were remained similar as the previous models at all four levels. Based on random slope estimates, greater policy effects on OSP resulted in larger effects on INCOME (r = 0.234) among provincials, but none on the county and facility levels. In addition, the correlation coefficients of OSP between intercepts and slopes were moderately negative among facilities (r = -0.328), and none at the county level. The correlation coefficients of INCOME between intercepts and slopes were negative among counties (r = -0.306), among facilities (r = -0.541), and none at the province level. The results of this model indicated a number of possibilities in practice. Firstly, at provincial level the non-essential medical income decreased more as the exposure time to the EMP policy became longer, and a reversed trend effects of the out-patient services. And such change trends were correlated between the two outcomes. Second, counties with more out-patient services initially tended to have smaller effects of the EMP policy over time, and so was for the INCOME or non-essential medical revenues. Thirdly, facilities having higher INCOME initially tended to achieved less effects of the EMP policy over time.Hospitals or healthcare facilities located in the same area are more similar in terms of number of staff, assets, scale and socio-economic environment, compared to hospitals in different areas. This phenomenon is called clustering  and is tFor the first and third research questions, the results indicated that provinces with higher mean value of OSP tended to have higher mean value of INCOME, and the same relationship of the two outcomes among counties. Although there was no previous study that directly examined this relationship, it is possible that prescriptions of non-essential medicines, excessive examinations by advanced equipment at out-patient services could rise medical revenue for hospital income as a compensation mechanism for the revenue lost due to the zero-marked essential medicine. However, this correlation was not observed at the hospital or facility level where the motivation of compensation was present. Further research into the implementation of the EMP policy and its impact at the facility level is guaranteed.For the second and third questions, we found positive dose-response effects for OSP, but negative dose-response effects for INCOME. The findings partly suggested the expected overall effects of the EMP policy, i.e., a longer exposure to the EMP policy was associated with an increased out-patient services overall, but partly a side effects of the financial issue for primary healthcare facilities, i.e., a reduced income associated with longer exposure to the policy. The positive effect of EMP on OSP was supported by some previous studies –9, 39. AFor the fourth question, we found that only at provincial level the policy effects on OSP and on INCOME was weakly positive among provinces (r = 0.234). This suggests that there was no evidence to support the hypothesis that effect of the EMP on OSP was linked with that on INCOME at facility or hospital level. Meanwhile, the results of third question were also indicated a lack of significant correlation between the mean values of OSP and INCOME at the hospital level. It is known that before implementing EMP, drug revenue was the main part of the primary hospitals’ total income . MeanwhiThough there was no evidence to suggest an association between OSP and INCOME, in terms of both their means and policy effects at hospital level, the moderately strong association between the two outcomes at the province level could be the result of complex contextual effects. Further research to reveal the context factors and hospital services are required. The phenomenon that hospitals with lower mean value of OSP or INCOME showed greater change in gaining more OSP or INCOME warrants further research on the mechanism by micro-level factors.The EMP has a positive effect on OSP, but a negative effect on INCOME. There was no evidence to suggest an association between the two outcomes in terms of their mean values and dose-response effects of EMP at the hospital level, which indicated that increased OSP did not bring enough additional INCOME. To ensure smooth implementation of EMP, sustainable mechanisms to compensate primary hospitals by government are needed.A number of limitations in the study should be reminded for the interpretation of the findings. Firstly, due to availability of the data, we did not have context variables at the levels of province and county to explain variabilities in the outcome variables at the corresponding levels. Second, we could not separate the true income revenue from subsidies ones in the INCOME variable. The total income of primary healthcare facilities came from a number of sources: medical revenue, fiscal subsidies, higher facilities subsidies and other incomes such as facility initiated complementary services for fees. The INCOME variable used in the study was the total income minus essential medical revenue. The higher facilities subsidies were usually small and variable among facilities, which had little impact on the finding. The finding of increased income in the study could be confounded with increasing of fiscal subsidies revenue. However, since the increasing of fiscal subsides was generally the same to all primary healthcare facilities nationwide, such effects would have be captured by the time effects in our model. The dose-response effects in relation to the policy should be unaffected. Thirdly, we used OSP, but the INCOME included outpatient and hospitalization parts; however, the medical income of primary hospitals came mainly from the outpatient part. Lastly, because the EMP was implemented in a temporal sequence, it led to different primary hospitals with different time exposed to the policy.