The popularity of ceramic restorations can be attributed to its life-like appearance, durability and biocompatibility and therefore ceramic restorations have been widely used for anterior and posterior teeth. Ceramic restorations have esthetic and biocompatible advantages but low fracture resistance. Since it has high flexural strength and fracture resistance, yttria-stabilized tetragonal zirconia polycrystal (Y-TZP) is the dental material most commonly used for the core of ceramic crowns and fixed dental prosthesis. In spite of improved mechanical properties, acceptable marginal adaptation and biocompatibility the whitish opacity of zirconia is an obvious esthetic disadvantage. The zirconia framework is often veneered with conventional feldspathic porcelain to achieve a natural appearance. However it is difficult to achieve sufficient bond strength between zirconia and the veneering material. Achieving sufficient bond strength between the veneering ceramic and the zirconia core is a major challenge in the long term clinical success of veneered zirconia restorations. The main objective of this study is to evaluate the effect of different surface treatments on the fracture strength of the two commercially available Zirconia namely Ceramill and ZR-White (AMANNGIRRBACH and UPCERA) respectively.2. The dimensions of the specimens are measured with a digital caliper (aerospace). The thickness and diameter of each specimen are calculated as the means of 3 measurements made at random sites. 80 discs from each Zirconia blank are divided into ten groups of 8 specimens each. Heat treatment after airborne-particle abrasion using 50 µm Al2O3 particles and 50 µm silica coated Al2O3 are applied to the upper and lower surfaces of the specimens. Each specimen is held under a pressure of 30 psi for 15 seconds at a direction perpendicular to the surface and at a distance of 30mm with an airborne particle abrasion device for the specimens in the airborne particle abraded groups. Heat treatments were performed at a starting temperature of 500°C, heating rate of 100°c/ min, ending at a temperature of 1000°C and 15 minutes holding time without vacuum for the specimens in the group 4, 5, 9 and 10. Airborne-particle abrasion mimicking the preparation for cementation was applied to the lower surfaces with 50 µm alumina and silica coated alumina particles for the specimens in the groups 6, 7, 8, 9 and 10. The specimens were cleaned for 15 minutes in an ultrasonic bath containing distilled water.Two commercially available pre-sinteredyttrium stabilized Zirconia blanks (ZR-White and Ceramill) from AMANNGIRRBACH and UPCERA respectively are used to produce the disc shaped specimens of size (15.2 ± 0.03 mm in diameter and 1.2 ± 0.03 mm thick) from each Zirconia blank. All disc shaped specimens are heated at 1200°C in a furnace for 2 hours to form homogenous tetragonal ZrOTo determine the fracture strength, a disc of 10 mm diameter was used to place 3 hardened steel balls of 3 mm diameter separated each other by 120 degrees . Each specimen was centrally placed on this disc. The lower surface mimicking the internal surface of zirconia was the tension side, facing the supporting device testing, while the upper surface mimicking the external surface of the zirconia core was loaded with a flat punch (1 mm in diameter). A universal testing machine was used to perform the test at a cross head speed of 1mm/min. The failure stress was calculated with the equation listed in ISO 6872. The results were then statistically analyzed. A post hoc test was used for pair wise comparisons.P<0.001), Airborne abrasion treatment to the specimens showed a significant difference between the abraded groups and the control group (P<0.001); further AMANNGIRRBACH specimens gave a higher value compare to the UPCERA specimens. The study also revealed that the heat treatment of the specimens gave significant value (P<0.001) compared to the control group, but heat treatment following the air abrasion reduces the fracture strength of the sample than the air abraded group.The mean fracture strength of commercially available Zirconia Ceramill (AMANNGIRBACH) showed a significant higher value compared to the ZR-White (UPCERA) Zirconia (in vitro fracture strength of Zirconia specimens treated with an airborne abrasion both on the veneering surface (50 µm silica coated Al2O3) and the cementing surface (50 µm Al2O3) was significantly higher than the heat treated and the control group.Within the limitation of this study, it is concluded that, the Airborne particle abrasion followed by the heat treatment reduces the fracture strength of the specimen than that ofthe group treated only by the air abrasives.The fracture strength of a commercially available Ceramill (AMANNGIRRBACH) is greater than that of a Zirconia from ZR-White (UPCERA) variety. The focus of dentistry in the present times is not only on the prevention and treatment of disease but also on meeting the demands for better esthetics. Accordingly, several treatment options have been proposed to restore the esthetic appearance of the dentition. The esthetics of a dental restoration depends on the chosen material, anatomical form, surface texture, translucency and colour. So to accurately reproduce the appearance of a natural tooth, considering the patterns of reflection and absorption of the light is not an easy task .Ceramics have been widely used in dentistry because of their ability to provide excellent cosmetic results that mimic natural teeth; they exhibit good mechanical strength when subjected to masticatory efforts. This rapid development of ceramic systems and processing enabled the treatment of teeth in both the anterior and posterior areas with primary objective of properly restoring form, function and esthetic excellence without the presence of metal. In 1774, the French pharmacist, Alex Duchateau and a Dentist named Nicholas Dubois De Chamant, managed to fabricate the first dental porcelain composition based on “green traditional” porcelain. However these prostheses were abandoned due to their high opacity. In 1838, Elias Wildman made porcelain that was more translucent close to the teeth . But, th2O3) as a reinforcing phase in dental porcelain in 1965  and Lithium disilicate based. In the first composition, Leucite is responsible for strengthening the ceramic when compared to feldspathic porcelain. In second the composition, the high content of crystalline Lithium disilicate enables a volume increase of up to 60% and high flexural strength (300 Mpa), allowing the design of fixed partial prosthesis of upto three units , 5. Due -1. The melting temperature of Zr is 1855°C and the boiling temperature is 4371°C. Zirconia was originally discovered by the chemist Martin Heinrich Klaproth in Germany in 1789 and was isolated by the Swedish chemist Jons Jacob Berzelius in 1824  is a chemical element and its name originates from the Persian “Zar-Gun” meaning golden in color. Zr belongs to the transitional metals and its atomic number is 40 and atomic mass 91.224g·mol2 much stronger compared to all other ceramic materials.“The addition of oxides such as Calcium, Magnesium, yttrium to the Zirconia can create partially stabilized zirconia (PSZ) which is stable at room temperature. PSZ usually consists of all three phases . The cubInspite of improved mechanical properties, acceptable marginaladaptation and biocompatibility the whitishopacity of zirconia is an obvious esthetic disadvantage. The zirconia framework is often veneered with conventional feldspathic porcelain to achieveanatural appearance. However, it is difficult to achieve sufficient bond strength between zirconia and the veneering material. Achieving sufficient bond strength between the veneering ceramic and the zirconia core is a major challenge in the long term clinical success of veneered zirconia restorations. After the fabrication of the zirconia core, surface treatments suchas airborne particle abrasion are typically performed on the zirconia surface before veneering. Heat treatment is recommended after airbornep article abrasion in dental practice in order to release the compressive stresses initiated by the air borne particle abrasion. The bonding between the zirconia core and the tooth is also important for the clinical success of zirconia restorations. Attempts have been made to create roughened ceramic surface to provide higher bond strength, thus creating a stronger micromechanical interlock. To increase the surface area for micromechanical bonding, airborne particle abrasion has been used. Some reports have suggested that zirconia treated with airborne particle abrasion easily develops surface cracks or fractures, and this may reduce its mechanical strength . However2. Results showed the greatest significance for the mechanical properties is the tetragonal (t) monoclinic (m) phase transformation that occurs by a diffusionless shear process at near sonic velocities, similar to those of martensite formation in quenched steel. The results obtained on plane fracture surfaces of various composites were correlated to mechanical property data and transmission electron microscopy observations (TEM) and were found to be in good agreement. This indicates that the method presented is a useful tool for estimating stress-induced transformation zone sizes and for checking the effectiveness of tetragonal particles introduced in a ceramic matrix , and sandblasting of In-Ceram ceramic did not change its surface composition. Sand blasting of all ceramic clinical restorations with feldspathic glass materials should be avoided, but for In-Ceram ceramic the volume loss was within an acceptable range and similar to that of noble metals .in vitro. The results show that the durable bond to alumina ceramic is achieved with the same resin composites and tribochemicalsilica coating of YPSZ did not result in a durable resin bond as it does on glass-infiltrated alumina ceramic  ceramics. There was no difference in mean strength between the sintered fine and coarse grained Y-TZP. Significant differences were found between the control group and ground fine grained material for both wet and dry grinding. Sandblasting significantly increases the strength in fine and coarse grained material. The highest amount of monoclinic phase and largest transformed zone depth (TZD) was found after sandblasting. This signifies that sandblasting may provide a powerful technique for strengthening Y-TZP in clinical practice. In contrast, grinding may lead to substantial strength degradation and reduced reliability of pre-fabricated zirconia elements . The results suggest that zirconia posts with ceramic cores can be recommended as an alternative to cast posts and cores. If a chairside procedure is preferred, zirconia or titanium posts with composite cores can be used .2O3), and 3) tribochemicalsilica coating. All samples were silanated following the surface treatment. The luting cements were bonded to In- Ceram specimens using Teflon tubes. All samples were thermocycled for 5,000 cycles altering between 5 and 55°C with 30-second dwell times. The shear bond strength values were measured in a universal testing machine with a cross-head speed of 1 mm/min. The result showed that, Shear bond strength of compomer cement following tribochemicalsilica coating was significantly lower in comparison to resin cements. Luting of In-Ceram with various resins provided varying degrees of bondstrengths that were significantly increased by the tribochemicalsilica-coating system  etching for 90 seconds with 5% hydrofluoric acid gel, 2) sandblasting  and sinusoidal (cyclic) loading on the spherical indenter, up to the point of initiation of radial fracture at the ceramic bottom surface immediately below the contact. For the polished specimen, data from the dynamic and cyclic test overlap, consistent with a dominant slow growth mode of fatigue. Strength of the sandblasted specimens shows significant reduction in the dynamic and cyclic tests, indicating of larger starting flaws. However shiftis considerably greater in the cyclic data, suggesting some mechanically assisted growth of the sandblast flaws , Procera AllCeram with AllCeram (PA), Procera AllZircon with CZR (PZ), and DC-Zircon with Vita D (DC). The veneering porcelain recommended by the manufacturer for each material was fired to the ceramic core. A metal ceramic (MC) combination was tested as a control group. Study showed that the bond strengths of 3 of the tested all-ceramic  were not significantly different from the control (MC) group .A study was done to assess the influence of sandblasting, grinding, grinding orientation, polishing and heat treatment on the flexural strength of a yittria stabilized tetragonal Zirconia. The specimens (160 beams) were equally divided into four groups according to the surface treatment . Twenty specimens from each group underwent heat treatment under the firing conditions used to fire a layer of porcelain and glaze. After treatment, the three-point flexure test was used to calculate the flexural strength and X-ray diffraction analysis was used to estimate.The study suggests that sandblasting and grinding may be recommended to increase the strength of dental Y-TZP, provided they are not followed by heat treatment. Fine polishing may remove the layer of compressive stresses and therefore, lower the mean flexural strength .2 particles  C silanization. The results showed that Silica coating with silanization either using 110 mm SiO2 or 30 mm SiO2 particles increased the bond strength of the resin cementto the zirconia-based ceramic significantly compared to that of airborne particle abrasion with 110-mm Al2O3  of In-Ceram Zirconia ceramics  were fabricated according to the manufacturer’s instructions and duplicated in resin composite. The specimens were polished and assigned to one of the following three treatment conditions: 1) Airborne particle abrasion with 110 mm alumina particles silanization, 2) Silica coating with 110 mm Silica particles  C silanization, 3) Silica coating with 30 mm SiOmm Al2O3 .2O3 particles + silanization, 2) silica coating with 30 SiO2 particles  + silanization. Conditioning the high-strength ceramic surfaces with silica coating and silanization provided higher bond strengths of the resin cement than with airborne particle abrasion with 110-μm Al2O3 and silanization  and zirconia-reinforced alumina-based (In-Ceram Zirconia) ceramics. Ten blocks (5 × 6 × 8 mm) of In-Ceram Alumina (AL), In-Ceram Zirconia (ZR), and Procera (PR) ceramics were fabricated according to each manufacturer’s instructions and duplicated in composite. The specimens were assigned to one of the two following treatment conditions: 1) airborne particle abrasion with 110-μm Alnization .A study was conducted to evaluate the effect of sandblasting, grinding, grinding orientation, polishing and heat treatment on the flexural strength of a yittria stabilized tetragonal zirconia polycrystals ceramic (Y-TPZ). The specimens (160 beams) were equally divided into four groups according to the surface treatment . Twenty specimens from each group underwent heat treatment under the firing conditions used to fire a layer of porcelain and glaze. After treatment, the three-point flexure test was used to calculate the flexural strength and X-ray diffraction analysis was used to estimate the relative amount of monoclinic phase. study suggests that sandblasting and grinding may be recommended to increase the strength of dental Y-TZP, provided they are not followed by heat treatment. Fine polishing may remove the layer of compressive stresses and therefore, lower the mean flexural strength .A study was done to Characterize the microstructure, composition and some physical properties of a glass-infiltrated alumina/zirconia-reinforced ceramic (IZ) and the effect of surface treatment on topography. Ceramic specimens were fabricated according to ISO6872 instructions and polished through 1mm alumina abrasive. Quantitative and qualitative analyses were performed using scanning electron microscopy (SEM), backscattered imaging (BSI), electron dispersive spectroscopy (EDS) and stereology. The elastic modulus and Poisson’s ratio were determined using ultrasonic waves, and the density using a helium pycnometer. The following ceramic surface treatments were used: AP-as-polished; HF-etching with 9.5% hydrofluoric acid for 90 s; SB-sandblasting with 25mm aluminum oxide particles for 15 s and SC-blasting with 30mm aluminum oxide particles modified by silica (silica coating) for 15 s. An optical profilometer was used to examine the surface roughness (Ra) and SEM–EDS were used to measure the amount of silica after all treatments. HF is an inadequate surface treatment for bonding resins to IZ ceramic. Results suggested that treating IZ with either SB or SC produced greater Ra values and the SC showed a significant increase in the surface concentration of silica, which may enhance bonding to resin via silane coupling  specimens were bonded to each other using an adhesive resin composite, glass ionomer, or zinc phosphate cement. Bonding strength was then determined by the shearing test. No significant differences were observed between SiC and Ale cement .A study was done to assess the effect of different surface treatments on the bond strength of veneering ceramics to zirconia. In a shear test, the influences of polishing, sandblasting, and silica-coating of the zirconia surface on bonding were assessed with five different veneering ceramics. In addition the effect of liner application was examined. With one veneering ceramic, the impact of regeneration firing of zirconia was also evaluated. Findings of this study revealed that bonding between veneering ceramics and zirconia might be based on chemical bonds. On this note, sandblasting was not a necessary surface pre-treatment to enhance bond strength and that regeneration firing was not recommended .A study was conducted to evaluated and compared the effect of three trialkoxysilane coupling agents on the bond strength of a Bis-GMA-based unfilled resin and a dimethacrylate-based resin composite luting cement to a zirconia ceramics . Six square-shaped zirconia specimens were used for each test group, a total of 72 specimens. The specimens in each group were all assigned to air-borne alumina particle abrasion followed by tribochemical silica-coating and silanization with 1 vol% solutions of 3 methacryloyloxy propyl trimethoxysilane, 3 acryloyloxypropyl trimethoxysilane,or 3 isocyanapropyl triethoxy silane in an ethanol–water mixture. The sample stubs were made of a Bis-GMA/MMA/DMAEMA resin or a commercial resin composite luting cement . They were bonded to the conditioned and silanized silica coated zirconia specimens using polyethylene molds. All specimens were tested at dry and thermo-cycled  conditions. The shear bond strength of resin stubs to zirconia was measured in a universal testing machine (cross-head speed 1 mm/min). Bonding of the experimental resin and commercial cement to silica coated zirconia is effective with 3 methacryloyloxypropyl trimethoxysilane or 3 acryloyloxypropyl trimethoxysilane, but not with 3-isocyanatopropyl triethoxysilane .2O3) particles; 2) tribochemical silica coating using 50 μm Al2O3 particles modified by silica; 3) no treatment. Each ceramic cylinder was duplicated in composite resin  using a silicon mold. Composite cylinders were bonded to conditioned ceramics using: 1) Calibra (Densply Caulk); 2) Clearfil Esthetic Cement (Kuraray); 3) Rely Unicem (3M ESPE). After 24h bonded specimens were cut into microtensile sticks that were loaded in tension until failure. Significant changes in zirconia surface roughness occurred after sandblasting. Bond strength of Clearfil cement to zirconia was significantly higher than that of Rely Unicem and Calibra, regardless of the surface treatment  were treated as follows: 1) Sandblasting with 125 μm aluminum-oxide  affects the polymerization shrinkage of dual-cured resin cements and to evaluate the effect of the ceramic discs on the curing speed of the cements during light exposure. Six commercial resin cements were used. Filler weight contents were determined. Four ceramic discs with thicknesses of 0.5, 1, 2 and 4mm, respectively were made. The results showed that the polymerization shrinkage and filler weight were inversely related. Both the transmitted light intensity and polymerization shrinkage decreased with increasing thickness of ceramic discs .in vitro the marginal fit of four-unit fixed partial dentures (FPDs) produced using three different computer aided design/computer aided manufacturing (CAD/CAM) all-ceramic systems before and after porcelain firing cycles and after glaze cycles. Within the limitations of this study, it was concluded that the three zirconium-oxide-based ceramic CAD/CAM systems demonstrated a comparable and acceptable marginal fit; however, the Lava system produced gap measurements statistically smaller than the Everest and Procera systems. The porcelain firing cycles and the glaze cycles did not affect the marginal fit of the zirconium-oxide-based ceramic CAD/CAM systems  made of In-Ceram Zirconia. All FDPs were inserted and cemented with glass-ionomer cement. Follow-ups were performed annually. During a mean observation time of 54 months, two FDPs failed . Two FDPs debonded and the veneering ceramic fractured in four cases. Three abutment teeth needed endodontic treatment and two additional abutment teeth exhibited secondary caries. Results suggest that posterior three-unit all-ceramic FDPs made from In-Ceram Zirconia may be a viable prosthetic treatment option with an outcome comparable to metal-ceramic FDPs .2 “seed” layer that would promote chemical bonding with traditional silanes. Microtensile testing results revealed that zirconia with a surface treatment of 2.6 nm SiO2 thick “seed” layer was similar in strength to the porcelain group (control). Mechanical data support that utilizing a gas-phase chloro-silane pretreatment to deposit ultra-thin silica-like seed layers can improve adhesion to zirconia using traditional silanation and bonding techniques  to facilitate viable, robust adhesive bonding using commercially available silanes and resin cements. Investigation focused on a novel approach to surface functionalize zirconia with a SiOchniques .2O3 particles; 2) 9.5% HF acid etching; 3) selective infiltration etching (SIE); 4) experimental hot etching solution applied for 10, 30 and 60 min; 5) no treatment. Ceramic discs surfaces were analyzed by atomic force microscopy (AFM) recording average surface roughness measurements of the substrate. It was concluded that Zirconia conditioning with the experimental hot etching solution may enhance ceramic roughness and improve the surface available for adhesion formation of micromechanical retention  were treated with (n=4): 1) airborne particle abrasion with 125 mm Aletention .A study was done to evaluate the bonding strength of the porcelain veneer to the zirconia core and to other various metal alloys .15 rectangular (4 × 4 × 9 mm) specimens each of zirconia (Cercon), base metal alloy (Tillite), high noble metal alloy (Degudent H) were fabricated for the shear bond strength test. The veneering porcelain recommended by the manufacturer for each type of material was fired to the core in thickness of 3mm. After firing, the specimens were embedded in the PTFE mold, placed on a mounting jig, and subjected to shear force in a universal testing machine. Load was applied at a crosshead speed of 0.5 mm/min until fracture. It was concluded that there was a significant difference between the metal ceramic and zirconia ceramic group in shear bond strength. There was no significant difference between the base metal alloy and the high noble metal alloy .The zirconia–resin bond strength was enhanced using novel engineered zirconia primers in combination with selective infiltration etching as a surface pre-treatment. The study was conducted to evaluate the effect of artificial aging on the chemical stability of the established bond and to understand the activation mechanism of the used primer .Selective infiltration etched zirconia discs  were coated with one of four novel engineered zirconia primers containing reactive monomers and were bonded to resin-composite discs (Panavia F2.0). Fourier transform infrared spectroscopy (FTIR) was carried out to examine the chemical activation of zirconia primers from mixing timeand up to 60 min. The bilayered specimens were cut into microbars (1 mm in cross-section area) and zirconia–resin microtensile bond strength (MTBS) was evaluated immediately andafter 90 days of water storage at 37ºC. Scanning electron microscopy (SEM) was used to analyze the fracture surface. The result revealed that, novel engineered zirconia primers produced initially high bond strength values which were significantly reduced after water storage. Long-term bond stability requires developing more stable primers .A study was done to evaluate the shear bond strength between an indirect composite material and zirconium dioxide (zirconia) ceramics after thermocycling. A total of 80 zirconia (Katana) discs were divided into five groups and primed with one of following agents: All Bond 2 Primer B (ABB), Alloy Primer (ALP), AZ Primer (AZP), Estenia Opaque Primer (EOP), and Porcelain Liner M Liquid A (PLA). An indirect composite material (Estenia C&B) was then bonded to the primed zirconia. One-half of the specimens (n=8) in each group were stored in distilled water at 37°C for 24 h, and the remaining eight specimens were thermocycled 5,000 times before shear bond strength testing. In conclusion, the study demonstrated that the use of an acidic functional monomer containing carboxylic anhydride (4-META), phosphonic acid (6-MHPA), or phosphate monomer (MDP) can yield durable bond strength between Estenia C & B indirect composite and Katana Zirconia .A study was done to determine whether the bond of veneering porcelain to a ceramic core in bilayered ceramics was similar to that of the metal ceramic control of well known behaviour. Six groups of nine specimens and the dimensions were 15 mm long and 8mm in diameter at the core, and 2 mm long and 8 mm in diameter for the veneer. The groups were GR. 1 (control group): CrNi alloy/d.SIGN (Ivoclar), GR. 2: IPS e.maxPress/IPS e.maxCeram (Ivoclar), GR. 3: IPS e.maxZirCad/IPS e.maxZirPress(Ivoclar), GR. 4: IPS e.maxZirCad/IPS e.maxCeram (Ivoclar), GR. 5: Lava Frame (3M ESPE)/Lava Ceram (3M ESPE) and GR. 6: Lava Frame (3M ESPE)/IPS e.max Ceram (Ivoclar). A shear strength test was used in all samples with a universal testing machine. The chosen cross head speed was of 0.50 mm/min. The bond strength of group 1 (control) was similar to groups 3 and 5. Group 2, whose core and veneer are both porcelains with a similar chemical composition, with silica as their main component, achieved the best adhesive results between both porcelains. The technique on zirconia cores that showed the higher results was the pressed technique. The lowest results were for the group using porcelains from different manufacturers .2O3 particle, grinding, sandblasting and liner application). One group had received no treatment. These disks were veneered with 3 mm thick and 5 mm diameter Cercon Ceram Kiss porcelain and SBS test was conducted (cross-head speed = 1 mm/min). Type of zirconia did not have any effect on bond strength between zirconia core and veneer ceramic. Surface treatment had different effects on the SBS of the different zirconia types and grinding dramatically decreased the SBS of white zirconia- porcelain  on shear bond strength (SBS) of zirconia core and its veneering porcelain. Eighty zirconia disks  were treated with three different mechanical surface conditioning methods  were layered with a veneering porcelain (5 × 3 × 3 mm). Three different surface conditioning methods were evaluated: polishing with upto 1200 grit silicon carbide paper under water cooling, airborne-particle abrasion with 110 μm alumina particles, and modification with zirconia powder coating before sintering. It was concluded that modifying the zirconia surface with powder coating could significantly increase the shear bond strength of zirconia to veneering porcelain .2 laser system (Group L). After surface treatment, porcelain powders were veneered on zirconia surface.A study was to done to compare the effects of three different surface treatments in enhancing porcelain zirconia bonding. Totally, 160 densely sintered zirconia specimens were prepared and randomly divided into four study groups: control , sandblasting (Group S), sandblasting followed by regeneration firing (Group SH), and laser irradiation (pulse mode) on a COHalf of the specimens in each group were evaluated without aging , and the other half was tested after being stored in water for one month (aging SBS). The results showed that both sandblasting and laser irradiation increased porcelain zirconia bond strength. The presented new modified laser pre-treatment might be an alternative way to sandblasting for improving zirconia/porcelain integration .in vitro study was done to investigate the influence of surface roughness and heat treatment of the zirconia and use of liner porcelain on the bond strength between veneering ceramics and zirconia framework. Debonding /crack initiation strength was determined according to ISO 9693. No significant difference was observed among conditions, except with use of a liner under heat treatment. Electron probe microanalysis revealed that components of the veneering ceramics remained on the zirconia surface after debonding, suggesting that fractures occur in the veneering ceramics and that improving the strength of the veneering ceramics themselves might increase the bond strength  were applied to the upper surface, and 2 treatments (untreated and airborne-particle abrasion) were applied to the lower surfaces to mimic the preparation for veneering and cementation. Particle sizes of 110 μm alumina were used. Result showed that the group with airborne-particle abraded lower surfaces showed significantly higher flexural strength than the untreated group. SEM images showed rough and irregular surfaces on the airborne particle abraded surface  core is used in an attempt to enhance the bond strength between the core and the veneering porcelain and to increase the surface area for cementation. An  surface .in vitro study was done to evaluate the effect of air particle abrasion protocols on the biaxial flexural strength, surface characteristics and phase transformation of zirconia after cyclic loading. Disc shaped zirconia specimen  were submitted to one of the air particle abrasion protocols, a) 50 μm alumina b)110μm silica coated alumina c) 30 μm silica coated alumina for 20 sec at 2.8 barpressure. All specimens were initially cyclic loaded  in water at 37ºC and subjected to biaxial flexural strength where the conditioned surface was under tension. Zirconia surface were characterized and roughness was measured with 3D surface profilometer. Phase transformations from tetragonal to monoclinic were determined by spectroscopy. The relative amount of transformed monocliniczirconia (FM) and transformed zone depth (TZD) were measured using X-ray diffraction (XRD) analysis. The data were analysed using ANOVA. Surface roughness was highest with 50 μm alumina (0.261 μm). After all air abrasion protocols, FM increased (15.02%-19.25%) compared to control group (11.12%). TZD also showed increased after air abrasion protocols, (0.83-1.07 μm) compared to control groups (0.59 μm). Air abrasion protocols increase the roughness and monoclinic phase but in turn abrasion with 30μm alumina particles coated with silica has increased the biaxial flexural strength of the tested zirconia . The thickness and diameter of each specimen are calculated as the means of 3measurementsmadeatrandomsites.Eighty disks each of commercially available ZR-White (UPCERA) and Ceramill (AMANNGIRRBACH) pre- sintered Zirconia block of size (15.2 ± 0.03 mm in diameter and 1.2 ± 0.03 mm thick) were fabricated. All disc shaped specimens are heated at 1200°C in a furnace for 2 hours to form homogenous tetragonal ZrOThe specimens were divided into 10 groups of 8 specimens each, and then heat treatment after airborne-particle abrasion and air borne particle abrasion alone were applied to the upper (veneering) and lower (cementing) surfaces of the specimens.Five treatments mimicking the preparation for the veneering were applied as follows:Group 1: no surface treatment;Group 2: airborne particle abrasion with 50 μm alumina on the veneering side;Group 3: airborne abrasion with 50 μm silica coated alumina on the veneering side;Group 4: airborne abrasion with 50 μm alumina and heat treatment after airborne particle abrasion;Group 5: airborne particle abrasion with 50 μm silica coated alumina and heat treatment after air borne abrasion;For the cementing surface;Group 6: airborne particle abrasion with 50 μm alumina on the lower (cementing) surface and no treatment on the veneering side;Group 7: airborne abrasion on the upper (veneering) surface and lower (cementing) surface with 50 μm alumina;Group 8: airborne abrasion on the upper surface with 50 μm silica coated alumina and lower surface with 50 μm alumina;Group 9: airborne abrasion on the upper surface with 50 μm alumina followed by Heat treatment and lower surface air-borne abrasion with 50 μm alumina only;Group 10: airborne abrasion on the upper surface  followed by Heat treatment and lower surface air-borne abrasion with 50 μm alumina.The air borne particle abrasion used was 50 μm alumina particles under pressure for 15 seconds at 30 psi in a direction perpendicular to the surface with an airborne-particle abrasion device for the specimens in the airborne-particle abraded groups.Heat treatments were performed at a starting temperature of 500°C, heating rate of 100°C/min, ending temperature of 1000°C and 15 minutes holding time without vacuum for the specimens in the group 4, 5, 9 and 10.Airborne particle abrasion mimicking the preparation for cementation was applied to the lower surfaces with 50 μm alumina and silica coated alumina particles for the specimens in the groups 6, 7, 8, 9 and 10. The specimens were cleaned for 15 minutes in an ultrasonic bath containing distilled water.To determine the fracture strength load, a disc of 10mm diameter was used to place 3 hardened steel balls of 3mm diameter separated each other by 120 degrees . Each specimen was centrally placed on this disc. The lower surface mimicking the internal surface of zirconia was the tension side, facing the supporting device testing, while the upper surface mimicking the external surface of the zirconia core was loaded with a flat punch (1mm in diameter).A universal testing machine was used to perform the test at a cross head speed of 1mm/min. The failure stress was calculated with the equation listed in ISO 6872.1 = radius of the support circle, r2 = radius of the loaded area, r3 =radius of the specimen thickness at fracture origin.where, S = the maximum tensile stress(MPa), P = total fracture load(N), d = specimen thickness(mm), v = poisson ratio, rSimilarly the commercially available Zirconia of other variety is tested in the same pattern and compared.This study was conducted to evaluate the effect of airborne particle abrasion using different types of alumina abrasive particles and heat treatment on the flexural strength of the two commercially available zirconia before veneering and cementation.Eighty disk seach of two commercially available ZR-White (AMANNGIRRBACH) and Ceramill (UPCERA) Y-TZP were divided into 10 groups of 8 specimens each, and then heat treatment after airborne-particle abrasion and airborne particle abrasion alone were applied to the upper (veneering) and lower (cementing) surfaces of the specimens.The airborne particle abrasion used was 50µm aluminaand50µm silica coated alumina particles under pressure 30 psi for 15 seconds at a direction perpendicular to the surface with an airborne particle abrasion device for the specimens in the airborne particle abraded groups 2,3,6,7,8,9 and 10.Heat treatments were performed at a starting temperature of 500°C, heating rate of 100°C/min, ending temperature of 1000°C and 15 minutes holding time without vacuum for the specimens in the group 4, 5, 9 and 10.The specimens were cleaned for 15 minutes in an ultrasonic bath containing distilled water.To determine the fracture strength load, a disc of 10mm diameter was used to place 3 hardened steel ballsof3mm diameters separated each other by 120 degrees . Each specimen was centrally placed on this disc. The lower surface mimicking the internal surface of zirconia was the tension side, facing the supporting device testing, while the upper surface mimicking the external surface of the zirconia core was loaded with a flat punch (1mm in diameter). A universal testing machine was used to perform the test at a cross head speed of 1mm/min. The failure stress was calculated with the equation listed in ISO 6872.1 = radius of the support circle, r2 = radius of the loaded area, r3 =radius of the specimen thickness at fracture origin.where, S = the maximum tensile stress (MPa), P = total fracture load (N), d = specimen thickness (mm), v = poisson ratio, rSimilarly, the commercially available Zirconia of other company is tested in the same pattern and compared.P<0.001). Table P<0.001) in the group 2, 3, 4, 5, 7, 8, 9, 10 and statistically significant (P<0.005) in the group 6. Table P<0.001) in group except group 5 which is statistically significant (P<0.005).The mean and standard deviation values of different commercially available Zirconia are listed in Table P<0.001) between the heat treated and the air abrasion group.Table P<0.001) between the surface treated group and the control group of ZR White (UPCERA) Zirconia.Table P<0.001) between the air abrasion and the control group. Figure Ceramill (AMANNGIRRBACH) showed highly significant value  as a reinforcing phase in dental porcelain was developed in 1965 , Magnesia (300 Mpa) and Zirconia 750 Mpa).However, both the concentration of alumina and Zirconia shown in these ceramic systems impart improvement of the optical qualities of the restoration, due to its high opacity . ZrO2 ceramics have three different crystallographic forms depending on temperature. At room temperature and up to 1170°C the material is in the monoclinic phase (M). Over this temperature and up to 2370°C the material transforms to the tetragonal phase (T) and then to the cubic phase (C) at yet higher temperatures  which is stable at room temperature. PSZ usually consists of all three phases  difference between the fired zirconia and the veneering material, plays a more important role than surface treatments in aging potential , and application of an alloy primer on shear bond strength of zirconia to enamel and concluded that airborne particle abrasion in combination with the application of a zirconia primer provides a durable bond strength. Surface grinding is a commonly used alternative for roughening the surface of ZrO2 to improve mechanical bonding (2O3), particle air-abrasion using Al2O3 or other abrasive particles ranging in size from 50 to 250 μm and grinding with a diamond bur. A novel surface roughening technique that has been explored for ZrO2 is selective infiltration etching (SIE). SIE uses a heat-induced maturation process to pre-stress surface grain boundaries in ZrO2 to allow infiltration of boundaries with molten glass.Zandparsa  bonding . There aet al, showing that the surface roughness of ZrO2 is significantly greater after SIE, when compared to particle air-abrasion or HF etching  ceramics showed that sandblasting may provide a powerful technique for strengthening Y-TZP in clinical practice  and ZR-White (UPCERA) Y-TZP were divided into 10 groups of 8 specimens each, and then heat treatment after airborne-particle abrasion and air borne particle abrasion alone were applied to the upper (veneering) and lower (cementing) surfaces of the specimens.The airborne particle abrasion used was 50 μm alumina and 50 μm silica coated alumina particles under pressure 30 psi for 15 seconds at a direction perpendicular to the surface with an airborne-particle abrasion device for the specimens in the airborne-particle abraded groups 2, 3, 6, 7, 8, 9 and 10.Heat treatments were performed at a starting temperature of 500ºC, heating rate of 100°C/min ending temperature of 1000ºC and 15 minutes holding time without vacuum for the specimens in the group 4, 5, 9 and 10.The specimens were cleaned for 15 minutes in an ultrasonic bath containing distilled water.To determine the fracture strength load, a disc of 10mm diameter was used to place 3 hardened steel balls of 3mm diameter separated each other by 120 degrees . Each specimen was centrally placed on this disc. The lower surface mimicking the internal surface of zirconia was the tension side facing the supporting device testing, while the upper surface mimicking the external surface of the zirconia core was loaded with a flat punch (1 mm in diameter). A universal testing machine was used to determine the fracture strength.According to the findings of this study, the mean fracture strength of commercially available AMANNGIRRBACH Zirconia showed a significant higher value compared to the UPCERA Zirconia , Airborne abrasion treatment to the specimens showed a significant difference between the abraded groups and the control group; further AMANNGIRRBACH specimens gave a higher value compare to the UPCERA specimens. The study also revealed that the heat treatment of the specimens increases the fracture strength compared to the control group, but heat treatment following the air abrasion reduces the fracture strength of the sample than the air abraded group.Restorations using Zirconia ceramics are processed through a series of steps including cutting, polishing, airborne particle abrasion, heat treatment and firing of the veneering porcelain. To achieve successful outcomes for Zirconia based restorations, each step with an effect on the properties should be thoroughly studied.In the present study, two surfaces of the specimens were divided into the upper and lower surface. Airborne particle abrasion of the upper and lower surface and heat treatment of the upper surface following air abrasion were applied to mimic the preparations for veneering and cementation. The upper surfaces were facing the loading piston, and the lower surfaces were facing the supporting device during the fracture strength test.et al reported that tensile stresses are distributed on the inner surface of the crown. Therefore, the lower surfaces were placed on the tension side in this study. Guzzato et al also stated that, the mechanical property of Zirconia specimens were dependent on the amount of monoclinic ZrO2 content of the lower surface, over which the tensile stress was distributed  and the cementing surface (50 µm Al2O3) was significantly higher than the heat treated and the control group. Airborne particle abrasion followed by the heat treatment reduces the fracture strength of the specimen than that of the group treated only by the air abrasives.The present in vitro study was conducted to evaluate the effect of airborne particle abrasion using different types of alumina abrasive particles and heat treatment on the flexural strength of two commercially available zirconia before veneering and cementation. Eighty disks each of commercially available Zirconia ZR WHITE (UPCERA) & Ceramill white (AMMANNGIRRBACH) Pre sintered Zirconia block of size . The readings were then subjected to statistical analysis. From the results obtained the following conclusions can be made. TheThe fracture strength of a commercially available Ceramill (AMANNGIRRBACH) is greater than that of a Zirconia from ZR-White (UPCERA) variety.In recent years, Zirconia restorations have become popular due to the increased interest in esthetic and mechanical property. The success of a Zirconia restoration largely depends on itsresistance to the fracture load, method of processing of the Zirconia material  and also the patient selection .Keeping this in mind, the present study was undertaken to recognize the effect of various surface treatments on the fracture strength of the two commercially available Zirconia.2O3.Two commercially available pre sintered yttrium stabilized Zirconia blanks ZR WHITE (UPCERA) & Ceramill (AMMANGIRRBACH) are used to produce the disc shaped specimens of size (15.2 ± 0.03 mm in diameter and 1.2 ± 0.03 mm thick) from each Zirconia blank. All disc shaped specimens are heated at 1200°C in a furnace for 2 hours to form homogenous tetragonal ZrO. the dimensions of the specimen are measured with digital caliper. The thickness and the diameter of each specimen are calculated as the means of 3 measurements made at random sites.80 discs from each zirconia blank are divided into ten groups of 8 specimens each heat treatment after airborne particle abrasion using 50 µm AlParticle and 50 µm silica coated Al2O3 and abrasion from 2 airborne particles alone are applied to the upper and lower surface of the specimens. Each specimen is held under pressure of 30 psi for 15 seconds at a direction perpendicular to the surface and at a distance of 30 mm with an airborne particle abrasion device for specimens in the airborne particle abraded groups. Heat treatments were performed at a starting temperature of 500°C heating rate of 100°C/min, ending temperature of 1000°C and 15 minutes holding time without vacuum for the specimens in the group 4, 5, 9 and 10. Airborne particle abrasion mimicking the preparation for cementation was applied to the lower surfaces with 50 µm alumina and silica coated alumina particles for the specimens in the groups 6, 7, 8, 9 and 10.The specimens were cleaned for 15 minutes in an ultrasonic bath containing distilled water.To determine the fracture strength load, a disc of 10mm diameter was used to place 3 hardened steel balls of 3 mm diameter separated each other by 120 degrees . Each specimen was centrally placed on this disc. The lower surface mimicking the internal surface of zirconia was the tension side facing the supporting device testing, while the upper surface mimicking the external surface of the zirconia core was loaded with a flat punch (1mm in diameter). A universal testing machine was used to perform the test at a cross head speed of 1 mm/min. The failure stress was calculated with the equation listed in ISO 6872. The results were then statistically analysed. A post hoc test was used for pair wise comparisons.P<0.001, airborne abrasion treatment to the specimen showed a significant difference between the abraded groups and the control group (P<0.001) FURTHER Ceramill (AMMANGIRRBACH) specimens gave a higher value compare to the ZR WHITE (UPCERA) Specimens. The study also reveal that the heat treatment of the specimens with the significant value (P<0.001) compared to the control group, but heat treatment following the air abrasion reduces the fracture strength of the sample than the air abraded group. Knowledge of such parameters enables the clinician to make appropriate choice in various clinical situations.The mean fracture strength of commercially available Ceramill (AMMANGIRRBACH) Zirconia showed a significant higher value compared to the ZR WHITE (UPCERA) Zirconia


I am very happy to start the New Year with recent news of progress in the health personnel licensing examinations in Korea.First, smart device-based testing was used to administer the Korea emergency medical technician licensing examination on December 2, 2017 in 5 cities in Korea, as previously announced [2 , and it cost 13.8 million dollars. It can provide a working space for 120 persons at the same time, and it will provide test makers with a more comfortable environment in a dedicated place.Second, the test construction center of the Korea Health Personnel Licensing Examination Institute was officially opened in Chungju, Korea on June 28, 2017 . ConstruIn 2018, the institute plans the following new projects: preparing permanent test centers and launching a committee on computerized adaptive testing. Currently, we usually rent test space from high schools to administer paper-and-pencil tests. However, for computer-based testing or computerized adaptive testing to be sustainably implemented, permanent test centers are required in the central cities of each province. The present form of smart device-based testing can be deployed in any location because tablet PCs are easy to handle and move. However, to adopt computerized adaptive testing, the PCs must have a wired internet or intranet connection . WirelesFurthermore, a task force team for computerized adaptive testing was launched in late 2017. As part of the preparation to implement computerized testing, a number of research projects are now under way: first, psychometric considerations, item pool construction, and administrative and financial support for the adoption of computerized adaptive testing; second, test equating of different item sets to implement the test at multiple times. In Korea, where this kind of testing has not been introduced on any high-stakes examinations, such as licensing examinations, we should be aware of the need to persuade not only medical health students and faculty members, but also the general population and government representatives of the merit of computerized adaptive testing as a way to estimate examinees’ ability more efficiently. If we adopt this testing format, examinees will be able to take the tests throughout the year.Journal of Educational Evaluation for Health Professions. Last year, 9 of the articles published in the journal described research that had been supported by a research grant from the institute. I hope that more articles supported by grants from the institute will be published in the journal in 2018. I will provide support for the journal to publish continuously as a way of helping medical health educators adopt a variety of innovations related to evaluation. I am also confident that brilliant articles will be published in the journal, making it an essential source of information in the field of educational evaluation.I have encouraged staff members of the institute and recipients of support from the institute’s research fund to publish their research output in


Although morning stiffness has long been recognized as a characteristic feature of rheumatoid arthritis (RA), it is no more included in the 2010 ACR/EULAR Classification Criteria or in the current major instruments for evaluating disease activity of RA. In this cross-sectional study, we aimed to determine the independent value and the optimal measurement of morning stiffness by clarifying the associations between morning stiffness and synovial inflammation.We enrolled 76 consecutive RA patients who underwent musculoskeletal ultrasound examination and agreed to participate in the study. In addition to asking the duration of morning stiffness, we asked patients to complete a diagram which represents the time course of their morning stiffness in the dominant hand. Based on this diagram, we calculated the severity and the diurnal improvement of morning stiffness. We also determined the activity of intra-articular synovitis in 11 joints and tenosynovitis in 8 tendons/tendon compartments in the same hand by using power Doppler (PD) ultrasound with a semiquantitative score (0–3).For intra-articular synovitis, swollen/tender joint counts more strongly correlated with total PD scores  than did any parameters of morning stiffness . For tenosynovitis, however, the severity on awakening and the improvement of morning stiffness more strongly correlated with total PD scores  than did swollen/tender joint counts . Multivariate analyses identified the severity on awakening and the improvement but not the duration of morning stiffness as factors that independently associate with the total tenosynovial PD score.Our data demonstrate a pathophysiological link between morning stiffness and tenosynovitis and also give an insight into the optimal measurement of morning stiffness. Our data support an independent value of evaluating morning stiffness in the management of RA. Morning stiffness has long been recognized by both patients and rheumatologists as a characteristic feature of rheumatoid arthritis (RA)  and was Nevertheless, morning stiffness is no more included in 2010 ACR/EULAR Classification Criteria for RA , 13 or iMost of the previous studies measured the duration of morning stiffness , 21, whiIn this study, we captured the time course of morning stiffness by employing a patient-reported diagram. We also determined the activity of intra-articular synovitis and tenosynovitis by using musculoskeletal ultrasound, which has been reported to be more accurate than clinical information –26, aimiWe recruited consecutive patients who fulfilled the 2010 ACR/EULAR Classification Criteria for RA , 13 and The study was approved by Ethics Committee of Chiba University and patients’ written informed consent was obtained according to Declaration of Helsinki.We collected information on patients’ characteristics and current treatment from medical records. We performed clinical evaluation of disease activity in the morning (8:30–12:00) and calculated DAS28 (C-reactive protein-based)  and SDAIWe asked patients about their representative morning stiffness during the past week in their hand with stronger arthritic symptoms. In addition to the duration (i.e. time until maximum improvement ), we askBased on this diagram, we determined the severity of stiffness on awakening, at the first 1/4 of total awake time, at the first 1/2 of total awake time, and at bed time. We also determined the diurnal improvement of morning stiffness at these time points by subtraction .st interphalangeal and 2nd-5th proximal interphalangeal joints, 1st-5th metacarpophalangeal joints, and wrist [radiocarpal/midcarpal/distal radioulnar joints]) were scanned from the dorsal aspect. For tenosynovitis, 8 tendons/tendon compartments (1st-5th flexor digitorum and extensor compartment II/IV/VI of the wrist) were scanned. Machine setting for PD ultrasound was optimized as previously described [Ultrasound was performed within an hour after clinical and laboratory evaluation in an air-conditioned room (temperature 24–26°C) by rheumatologists trained for musculoskeletal ultrasound, who were blinded to the clinical/laboratory information. Gray-scale (GS) and power Doppler (PD) ultrasound examination of dominant hand was performed using either a HI VISION Avius, a HI VISION Ascendus , or an Aplio XG , depending on availability. For intra-articular synovitis, 11 joints . Normally distributed continuous data were summarized with mean and standard deviation (SD). Non-normally distributed data were summarized with median and interquartile range (IQR) and were analyzed using Spearman’s correlation coefficient. Categorical data were summarized with number and percentage. Multivariate linear regression analysis was performed using forced entry method. Two-sided A total of 76 patients fulfilling the inclusion/exclusion criteria were enrolled. These patients were predominated by women (78.9%) with a mean age of 58.4 (SD 14.6) years and a median disease duration of 24 (IQR 8–63.75) months. Rheumatoid factor (RF) and anti-citrullinated protein antibody (ACPA) had been positive in 84.2% and 77.6%, respectively .Nineteen patients (25.0%) underwent ultrasonography for diagnosis and 17 (22.4%) were treatment-naïve. Fifty-seven patients (75.0%) underwent ultrasonography for the evaluation of disease activity. Thirty-nine patients (51.3%) were receiving methotrexate with a median dose of 10 mg/week, 19 (25.0%) salazosulfapyridine, and 15 (19.7%) biologics . Twenty-two patients (28.9%) were receiving corticosteroids with a median dose of prednisolone 4.5 mg/day and 42 (55.3%) non-steroidal anti-inflammatory drugs (NSAIDs) .Median DAS28 and median SDAI were 3.1 (IQR 2.1–4.2) and 12.8 (7–20.675), respectively .Clinical and sonographic findings in the dominant hand are summarized in We first examined the associations between clinical findings in the dominant hand and total PD scores in the same hand by univariate analysis . For intWe next examined whether the parameters of morning stiffness independently associate with total PD scores by multivariate analysis . We testThe major strength of this study is that we determined the activity of intra-articular synovitis and tenosynovitis with PD ultrasound, which has been reported to be more accurate than clinical information –26. Our Tenosynovitis has been recognized as a significant and important feature of RA in studies using modern imaging modalities. Tenosynovitis has been shown to be prevalent and responsive to anti-rheumatic treatment , 31, assAnother advantage of this study is that we devised a method using a patient-reported diagram to capture the time course of morning stiffness. Our data demonstrate that the severity and the diurnal improvement of morning stiffness are more closely related to the activity of synovial inflammation than is its duration. This does not only apply to tenosynovitis but seems to also apply to intra-articular synovitis Tables  and 2. TThis study has some limitations. Firstly, relatively small sample size did not allow for stratification by background information such as disease duration and activity. Results may have been different in patients with longer disease duration or higher disease activity with a larger number of involved joints. In addition, we cannot exclude the possibility of selection bias although patients’ characteristics were representative of RA patients in our daily practice. Secondly, our data may not be applicable to joints other than hands. However, hands are the region that is most frequently involved in RA and where patients most frequently reports morning stiffness , and areIn conclusion, our data demonstrate a pathophysiological link between morning stiffness and tenosynovitis and give an insight into the optimal measurement of morning stiffness. Moreover, our data add to the evidence supporting an independent value of evaluating morning stiffness in the management of RA.S1 File(XLSX)Click here for additional data file.


Pioneerism with theinterval of evaluation extended from three to four years, and the record and collection ofdata of the Programs through an Furthermore, the criteria used for evaluation of Academic Programs were improved and betterdelineation, identity, productivity and evaluation process of Professional Master Programswere implemented, which were exhaustively discussed and constructed with peer collaborationin seminars and forums, in addition to the exercise of a partial evaluation of the Programswith wide debate of results in a Seminar entitled “Half Term Picture”. The incorporation ofan evaluation process with a quality seal for the books produced in the Area was also implemented in the quadrennium 2013-2016, joining the traditional process ofqualification of periodicals in force.Fifty-three academic programs and 21 professional master programs in operation in the fiveregions of the country were evaluated, showing an increase of nearly 30% in the presentquadrennium, in relation to the 2010-2012 triennium, with a still asymmetrical distributionof courses, which are concentrated in the Southeast (42.9%), with advances in the Northeast(25.9%) and South (21.4%), and low numbers in the Midwest (8.0%) and North (1.8%)In this group, professional master programs stand out for their remarkable expansion in thelast six years, with a relative growth of 156%, representing 20.5% of the approved coursesof the Nursing Area in December 2016. These courses target the training of professionalsfor health services and the consolidation of the Unified Health SystemIn view of the strengthening of Nursing as Subject and Science, the expansion of the offerof PhD programs and interinstitutional academic cooperation initiatives became evident.With 38 doctoral programs, although none in the North of the country, the investments toreduce the asymmetries have been directed through academic solidarity, evidenced especiallyin the Federal and State Universities of Amazonas, Federal University of Acre andUniversity of Rondônia, with the offer of special classes outside the Headquarterfacilities, in the “Inter-institutional Doctoral program” (Dinter). The expansion of doctoral training has also been demonstrated beyond the borders of thecountry, reaching Latin America, with the assistance to implement Stricto Sensu Programsand reception of foreign professionals to conduct courses in the headquarters of thePrograms. Solidary actions of international academic cooperation, such as the offer of aDinter to PUC-Chile, and training of doctors to countries such as Mexico, Peru andColombia, among others, strengthen the Nursing Area and the Brazilian Programs.3.Since the implementation of the first course in 1972ranking of theScopus/SCImago database in 2006 to the seventh in 2016 in terms of number of documents,overtaking the United States, United Kingdom, Australia, Canada, France and China. Thechallenge is to maintain stability in the ranking in citation ofpublications and raise the position in the H index, which has remained at 96, correspondingto the 22nd placeThe quantitative-qualitative growth of the Programs reverberated in the expressivescientific production evidenced in this quadrennium, which counted the publication of16,321 articles, representing a relative growth of 77% in relation to the last triennium.The impact of this production can be seen in the international projection of BrazilianNursing, in the jump from the eleventh position in the expertise of professors who, as seen in the evaluationof the Programs, have worked on many and diverse work fronts in institutions, associations,societies, scientific journals and international events. The international visibility of Researchers and Programs of the Nursing Area is expressedthrough various activities that take place in the framework of agreements, technicalcooperation and other types of interinstitutional partnerships, as well as initiatives ofincentive of research and events that increase mobility actions of researchers andstudents. These insertions have resulted in institutional academic ackowledgement,objectified in the stricto sensu postgraduate education, financed research, relevantpositions in the management/headship of services and academia, among others. The data haveshown the good placement or mobility of graduates with a rise in the labor market.Because these are programs whose goal is to qualify professionals, indicators to evaluatethe insertion of new doctors in the labor market have also been applied in the evaluationof the Area and have evidenced the important work carried out in the field ofInternationalization has been the target of Nursing training, with expansion ofinternational collaborative networks, exchanges of professors and students, and attractionof foreign professionals for qualification in Brazil, both in master’s and doctoralcourses, reaffirming the excellence of the Programs of the Area. In the meantime, thescientific production of international circulation is the one that most strongly evidencesthe capillarity of diffusion and recognition of the Nursing Science produced in Brazil, somuch that 40% of the weight of the evaluation of potential programs classified as 6 and 7regarding international excellence is attributed to this aspect, followed by internationalparticipation (25%) and complemented by the analysis of indicators of faculty leadership(15%), nucleation (10%), and solidarity (10%)When this scientific production is done in partnership with foreign researchers, itdistinguishes and discriminates the international excellence of the Programs. In thisquadriennium, among the 3,198 articles produced by the seven programs to whichinternational excellence (6 and 7) was assigned, 10.7% were published with foreignauthors.Besides increased scientific production, the number of qualified journals in which theNursing Programs have published increased by 30%, from 1,213 in the previous triennium to1,579 in the present quadriennium, 39% of them with JCR/WoS and 53% with H/SCImagoindexDespite the increase of collaborative and multicentric research in partnership with foreignresearchers, with consequent increase in joint scientific production, this aspect of theinternationalization process still needs to improve, as well as the development oftechnological production in the Nursing Area, co-advising, double degrees, provision ofclassess in the English language and the raising of funds in foreign agencies/institutions.These represent challenges to be overcome in the coming years, requiring a strategic planwith actions to be implemented by the Programs.In the process of evaluation of the present quadrennium, there were pioneerisms, as said,but portrayed achievements in itself, in the overcoming of adversities of the contemporaryworld, of shortage of funding, and of the impacts of retirement plans that imply thereformulation of the teaching staff. Nonetheless, the Area is aware of the challenges to befaced and remains firmly committed to advancing in training and evaluation processes thatcause impacts with quality, applicable, and change-generating academic-scientificproducts.


In addition, a significant difference was also noted between the rs12979860 allele frequencies of liver graft biopsies and donors' sera  (p = 0.012) and of liver graft biopsies and recipients' sera on POD0  (p = 0.002), POD7  (p = 0.016), and POD30  (p = 0.008). This phenomenon was confirmed by pyrosequencing of hepatocytes isolated by LCM. Following LDLT, the TT-to-GT IL-28B genotype modification predominated in rs8099917, and the CC-to-CT modification predominated in rs12979860. In conclusion, these modified phenomena suggested that the selected donor with a predictable and favourable IL-28B genotype will not confer a benefit on the recipient in the living donor liver transplantation setting.The aim of this study is to elucidate the biogenetic modification of donor and recipient interleukin-28B (IL-28B) genotypes in liver graft biopsies after living donor liver transplantation (LDLT) for chronic hepatitis C virus- (HCV-) related, end-stage liver disease. Fifty liver graft biopsies were collected from recipients during LDLT treatment for HCV-related, end-stage liver disease. DNA was extracted from all 50 liver tissues, and the IL-28B single-nucleotide polymorphisms (SNPs) rs8099917 and rs12979860 were studied for allelic discrimination by real-time PCR analysis. Blood samples were obtained from donors and recipients on postoperative day 0 (POD0), POD7, and POD30. We randomly selected five liver biopsies and isolated the hepatocytes by laser capture microdissection (LCM) to evaluate genotype modifications resulting from LDLT. After LDLT, the IL-28B SNP rs8099917 was identified not only in the liver graft biopsies and donors' sera , but also in liver graft biopsies and recipients' sera on POD0 , POD7 , and POD30 . A significant difference was observed between the rs8099917 allele frequencies of liver graft biopsies and recipients' sera on POD30 ( In hepatitis C virus (HCV) infection control, human interleukin 28B (IL-28B) genetics may play a role in patients' selection and treatment decisions. The most common IL-28B single-nucleotide polymorphisms (SNPs) are rs8099917 and rs12979860, which are associated with spontaneous clearance or sustained viral response with interferon treatment of HCV genotype 1 , 4. IL-2This research was conducted in accordance with the World Medical Association Declaration of Helsinki (2000) and our own institutional standards and was approved by the Institutional Review Board of Chang Gung Memorial Hospital . Written informed consent for participation in this study was obtained from each participant or from a parent or guardian for child participants.Fifty liver graft biopsies were obtained from recipients after LDLT when elevated liver function was observed or acute rejection was suspected clinically, as described , 6. DNA We studied samples from 50 donor and recipient pairs who underwent LDLT in our Liver Transplantation Centre. Blood samples were obtained from the donors and recipients at three different time points: postoperative day 0 (POD0), which represented the initial recipients' status mixed with donors' characteristics; POD7, which represented an adjustment period with active immune responses between liver grafts and peripheral mononuclear cells; and POD30, which represented a late, stabilised status after LDLT. The clinical profiles of the 50 pairs of donor and recipient were showed on IL-28B SNP rs8099917 and rs12979860 genotypes were studied in liver tissues, donor's blood samples, and recipient's blood samples on POD0, POD7, and POD30, using a 7500 Fast Real-Time PCR System  with Custom TaqMan SNP Genotyping Assays (Applied Biosystems) for allele discrimination.μm single-layer frozen sections were subjected to LCM, using a laser microdissection and pressure-catapulting microscopic system . Over 4,000 single-layer cells were pooled per sample, dissolved in lysis buffer, and DNA was extracted after PCR amplification.Liver graft biopsy tissues were stored at −80°C in OCT compound, and unstained 5 μL reaction volume. The PCR conditions consisted of initial denaturation at 95°C for 15 min, followed by 45 cycles of denaturation at 94°C for 30 s, annealing at 60°C for 30 s, and extension at 72°C for 30 s, with a final extension step at 72°C for 10 min. The PCR products were separated on a 2% agarose gel. The obtained product had a length of 125 bp.Genomic DNA was extracted from liver graft tissues and peripheral blood using a genomic DNA purification kit followed by biotinylated DNA PCR amplification. The rs8099917 SNP was identified by PCR-restriction fragment length polymorphism (PCR-RFLP) assay. Genotyping of the rs8099917 SNP was performed by pyrosequencing with a PyroMark Q24 System , according to the manufacturer's recommended protocol. Primers were designed for pyrosequencing using PyroMark Assay Design Software, version 2.0. For the PyroMark PCR assay, we used a forward primer (5′-TGTACCACCCAGCTTAACGA-3′) and a 5′-biotinylated reverse primer (5′-biotin-GGTCCAAACAGGGAAGAAAT-3′) [p values < 0.05 were considered statistically significant.Statistical analyses were performed using SPSS software . Since the donor sera and recipient liver grafts could be from the same original source, comparisons of the IL-28B rs8099917 and rs12979860 SNP genotypes between the donors and recipients were performed at different time points by the McNemar–Bowker test. For the three haplotypes in the case of rs8099917, 3-by-2 analysis with the TT, GT, and GG genotypes was performed to compare the differences between the recipient liver grafts and donor sera on POD0, POD7, and POD30. In the case of rs12979860, as there would only be one genotype (TT) in the donor serum, a 2-by-2 analysis was performed for CT and CC to evaluate the statistical significance. All liver graft biopsies and recipient serum samples expressed only two genotypes in this study on POD0, POD7, and POD30. p < 0.05). The serum HCV-RNA was obtained after the liver biopsy. Antiviral treatment was scheduled based on the parameters of our liver transplantation program, as previously reported.Of the 50 recipients, liver biopsies for 18 cases (36%) were performed within 1 month and for 32 cases (64%) were performed more than 1 month after LDLT transplantation. The acute rejection rate was 14% (7/50) in this study. Following tissue biopsy, we found that 54% (27/50) of the allografts presented with chronic hepatitis related to recurrent HCV infection with Ishak's system- (ISHAK-) modified Histology Activity Index (HAI) necroinflammatory scores of 4 to 8 and ISHAK-modified fibrosis scores of 1 to 3. We observed a change in fatty acid contents in 10% (5/50) of the samples, three of which  showed a nonalcoholic fatty liver disease- (NAFLD-) activity score of 5, which is diagnostic of nonalcoholic steatohepatitis. We also found that 8% (4/50) and 14% (7/50) of the samples showed cholangitis and nonspecific reactive changes, respectively. In our series, detection of serum HCV-RNA was negative in 12 recipients  before LDLT and in 40 recipients  after LDLT (p = 0.039) (p = 0.012) and between liver graft biopsies and recipients' sera on POD0  (p = 0.002), POD7  (p = 0.016), and POD30  (p = 0.008)  . In addi= 0.008) .Based on the donors' serum IL-28B rs8099917 genotypes, five cases  served as index cases for choosing related liver graft biopsies when clinically required after LDLT. We analyzed the liver tissues from the five recipients to isolate the hepatocytes via automated and noncontact LCM. Single-cell LCM was performed to capture over 4,000 hepatocytes in grids and preserve their genomic relationships. This process was followed by pyrosequencing. For each of the five randomised cases, the isolated hepatocytes from liver graft biopsy tissue and a given recipient's serum on POD0 were analyzed by PCR-RFLP  and subsAlthough IL-28B is encoded in the human genome 19q), in this study, we found that some genotypes were time-dependently modified after LDLT from TT (in a given donor's serum) to GT (in the corresponding liver graft biopsy tissue) in rs8099917 and from CC to CT in rs12979860. Allelic discrimination becomes even more complex when sera following LDLT are examined. Moreover, leukocyte and stem cell populations from the donor's liver will in effect contaminate the blood samples. For example, a recipient's TT genotype with a donor's GG liver genotype may be identified as a GT heterozygote, as a fraction of the peripheral blood mononucleocyte population from the donor's liver is present in the blood sample. Although the ratio of host TT cells to donor GG cells may be high, when quantified by qPCR, it may still be observed as a heterozygote, even though two distinct cell populations are present. The same applies when genotyping graft tissue that may be infiltrated with numerous host immune cells with a different genotype; hence explaining the differences we found in the donors' sera and liver graft tissue genotypes. LCM has been previously shown to be a useful method for purifying the original source when isolating individual hepatocytes to explore the IL-28B rs8099917 genotype q, in thi. This phIn conclusion, IL-28B genotype modification was predominant, not only in terms of the TT-to-GT modification in the rs8099917 SNP, but also in terms of the CC-to-CT modification in the rs12979860 SNP. This phenomenon was determined by pyrosequencing after microdissection of isolated hepatocytes following LDLT.


Sequential and single grafting are two surgical procedures of coronary artery bypass grafting. However, it remains unclear if the sequential graft can be used between the right and left coronary artery system. The purpose of this paper is to clarify the possibility of right coronary artery system anastomosis to left coronary system.A patient-specific 3D model was first reconstructed based on coronary computed tomography angiography (CCTA) images. Two different grafts, the normal multi-graft (Model 1) and the novel multi-graft (Model 2), were then implemented on this patient-specific model using virtual surgery techniques. In Model 1, the single graft was anastomosed to right coronary artery (RCA) and the sequential graft was adopted to anastomose left anterior descending (LAD) and left circumflex artery (LCX). While in Model 2, the single graft was anastomosed to LAD and the sequential graft was adopted to anastomose RCA and LCX. A zero-dimensional/three-dimensional (0D/3D) coupling method was used to realize the multi-scale simulation of both the pre-operative and two post-operative models.Flow rates in the coronary artery and grafts were obtained. The hemodynamic parameters were also showed, including wall shear stress (WSS) and oscillatory shear index (OSI). The area of low WSS and OSI in Model 1 was much less than that in Model 2.Model 1 shows optimistic hemodynamic modifications which may enhance the long-term patency of grafts. The anterior segments of sequential graft have better long-term patency than the posterior segments. With rational spatial position of the heart vessels, the last anastomosis of sequential graft should be connected to the main branch. Veins from a certain part of the patient’s body are grafted to the coronary arteries in order to bypass atherosclerotic narrowing and enhance the blood supply to the coronary circulation supplying the myocardium . ApproxiThere are three main coronary artery systems, which are RCA, LAD and LCX. The sequential graft is used alone among the different systems. Commonly, 50% of the blood supply to left ventricle (LV) is from LAD. In order to ensure the LV flow rate, the branches of LAD are usually used as the first anastomosis in clinical application. So did this research. But there are some doctors and researchers have come up with a question whether the sequential graft can be adopted between RCA and LAD, or between RCA and LCX. So in this study, two surgical options with both sequential graft and single graft, Model 1 and Model 2, were applied on a patient-specific model with multi-branch lesions. In Model 1, the anastomotic method was abbreviate as aorta (AOA)–LAD–LCX and AOA–RCA. In Model 2, the anastomotic method was abbreviate as AOA–RCA–LCX and AOA–LAD.The 0D/3D coupling method was used in this numerical simulation to perform a numerical simulation by coupling the lumped parameter model  and 3D vascular sub-models. This method has been used in some new hemodynamic researches and proven useful in studying blood flow in the cardiovascular system –8.The adaptive response to hemodynamic factors, i.e., WSS, may lead to SVG failure –11. WhilThis work studies the hemodynamics of right coronary artery system anastomosis to left coronary system. In order to evaluate the novel multi-graft design (AOA–RCA–LCX and AOA–LAD), a computational fluid dynamics method was used to compare the novel grafts with the normal multi-graft (AOA–LAD–LCX and AOA–RCA) in terms of hemodynamic performance.In this study, a group of patient-specific anatomy data was acquired from a male patient with CAD obtained by Beijing Anzhen Hospital in China. Informed consent was obtained. The patient’s personal information was anonymized and de-identified prior to analysis. The cardiac output was 5.80 L/min, the systolic aortic pressure was 122.00 mmHg, and the diastolic aortic pressure was 84.00 mmHg. Two hundreds and seventy-one slices with 512 × 512 pixels are used for 3D reconstruction. The distance between each adjacent slice is 1 mm. Three slices of the patient’s CT images are shown in Fig. The 3D sub-models were meshed to generate the computational models. Hexahedral mesh was generated mainly by using the size-control method with the assistance of the commercial software ANSYS-CFX (ANSYS™). The mesh was refined in the areas of interest to precise the simulation results as the resolution was improved. The number of nodes and elements in the two sequential models were within the same magnitude and all more than the number of computational requirements. A steady state grid sensitivity analysis was carried out to make sure that the number of the nodes and elements were large enough to ensure the stability and reliability of simulation results . Solutio3, and the dynamic viscosity was assumed to be 3.50 E-3 Pa· s.In the 3D simulation the assumption of rigid wall was applied. The blood flow was treated as the incompressible viscous Newtonian fluid. The density of the blood flow was assumed to be 1.05 E3 kg/mThe LPM used in this study was referenced from Charles A. Taylor’s previous study , 14. On E(t) is the time-varying elastance (mmHg/mL). V(t) and P(t) are the ventricle volume (mL) and pressure (mmHg) respectively. V0 is the reference volume (mL). Mathematically, the function was used as the approximation.En(tn) is the normalized time-varying elastance.tc is the cardiac cycle interval (s), Tmax = 0.2 + 0.15 tc. In this paper, we set Emax = 2.0, Emin = 0.002458 and tc = 0.8 s.In the compartment of the ventricle, the function of pressure–volume relationship was applied to demonstrate the cardiac cycle of the left and right ventricle.The value of the parameters in the 0D network of coupled models were based on data from research into the modeling of coronary arteries . The genThe aortic flow rate and pressure of the patient-specific model were calculated as shown in Fig. The outlet flow rate of the LAD branches (a–g branches) was summed as the LAD flow rate. The outlet flow rate of the LCX branches (h–l branches) was summed as the LCX flow rate. The outlet flow rate of the RCA branches (m–r branches) was summed as the RCA flow rate. The coronary flow rate was illustrated in Fig. The graft flow was frequently used to evaluate the short-term outcomes of CABG . In otheFurthermore, the time-averaged flow rate of sequential graft and single graft were calculated in Fig. 2 (t = 0.13 s) and 433.35 mm2 (t = 0.58 s). While in Model 2, the area of low WSS was 86.30 mm2 (t = 0.13 s) and 1250.04 mm2 (t = 0.58 s). It could be found that the low WSS area of grafting in Model 1 was obviously smaller than that in Model 2 at 0.58 s.Wall shear stress (WSS) of the grafts in two models are plotted. The waveforms of area-averaged WSS on the grafts are illustrated in Fig. Oscillatory shear index (OSI) is a measure of the temporal and spatial variations of local WSS. The OSI was calculated according to the expression in Eq. . The valFlow rate of grafting was frequently used to evaluate the short-term outcomes of CABG. From the results, it could be found that there was no significant difference in flow rate of coronary artery between two models. This phenomenon meant that the sequential graft and the single graft of two models did not change the flow distribution to every coronary artery branches. The flow rate distribution of every branch was mainly controlled by the outlet pressure and the resistance. In terms of the blood supply mechanism, the sequential graft was feasible from RCA branch to LCX branch.2 (t = 0.58 s), while in Model 2, the area of low WSS was 1250.04 mm2. The low WSS area of grafting in Model 1 was obviously smaller than that in Model 2 at 0.5280 s. It could be found that the low WSS region mainly appeared on the sequential graft to the LCX.The different multi-grafts options would affect the long-term patency of graft. Some researches declared that low WSS might decrease the long-term patency of the graft , 17 or lIf we assumed that the diameter of sequential grafts was constant, the WSS was proportional to the velocity of flow. So we hold that (i) when the flow rate of cross-section 1b and 2c was the lowest in two models, the WSS of graft to LCX was smallest; (ii) the anterior segments of sequential graft could have better long-term patency than the posterior segments.2, while the area of high OSI was 48.54 mm2 in Model 2. Moreover, the area-average OSI of the grafts in Model 1 and 2 was 7.99 E–3 and 1.18 E–2 respectively. Therefore, the long-term patency of Model 1 was better than that of Model 2.Some study indicated that lower OSI would decrease the opportunity of vascular intimal hyperplasia , 19. HigThis paper, based a patient-specific model, is to clarify the possibility of right coronary artery system anastomosis to left coronary system. But it can’t prove that the conclusions have universality to other patients.Fractional flow reserve (FFR) is an important index of coronary stenosis, isolates a specific period in diastole, called the wave-free period. For one patient, the value of FFR decrease with the Stenosis degree. But different patient may have different critical stenosis degree result in myocardial ischemia and low FFR. Therefore, the relationship among stenosis degree, FFR and sequential graft from left coronary system to right coronary system is also an interesting research content which may be studied in the future.Some limitations existed in this study. First, the rigid wall hypothesis was applied in the 3D simulation. The fluid–structure interaction was not used because it would cost much time in the 3D calculation. Second, there were only sequential graft and single graft considered in two models, since majority studies proposed that sequential graft was better than the other type graft. The results and conclusions might be different for other surgical procedures or stenosis.It is feasible that right coronary artery system anastomosis to left coronary system. Two post-operative models with different multi-grafts options were built to discuss the short-term outcomes and long-term patency by investigating the hemodynamic effects based on the 0D/3D coupling simulation. There were no significant differences in the short-term outcomes on two models which met the demand of patient flow supply. But the surgical method of Model 2 had more areas of low WSS and high OSI. Therefore, Model 2 had better long-term patency than Model 1.We come to the conclusion that (i) a branch of LAD also can be the last anastomosis in sequential graft; (ii) when the spatial position of the heart vessels is permitted, the last anastomosis of the sequential graft should reach to the main branch with large flow demand.


The International Protection of Adults, there is an increasingly international dimension to mental capacity law given that socio-economic changes in the last 50 years have resulted in legal practitioners having to contend with situations where an adult may have more than one nationality, own property in different jurisdictions, or becomes incapacitated while abroad (p xi).What are the basic principles of mental capacity law in England and Wales and how do they apply in practice? What happens when an adult has a mental or physical incapacity and so is unable to manage their own affairs, yet owns property in several different jurisdictions? Or becomes incapacitated in a jurisdiction other than where they usually live? The importance of these areas is well rehearsed, and health care law academics are now well versed in reciting why these areas of law are of increasing significance. It is well known, for example, that the number of people diagnosed with dementia is expected to continue rising and it is increasingly likely that practitioners from both medicine and social work will be required to have a working knowledge of the provisions of the Mental Capacity Act 2005. Similarly, and as Paul Lagarde notes in his Foreword to A Clinician’s Brief Guide to the Mental Capacity Act aims to provide a comprehensive overview of the 2005 Act—the statute that has regulated the treatment of those who lack mental capacity in England and Wales since 2007. The predominant focus of The International Protection of Adults, in contrast, is the Hague Convention on the International Protection of Adults (hereinafter Hague 35). This was an attempt to set up a mechanism with which to facilitate cross-border protection of adults with either a mental or physical disability that renders them unable to protect their own interests or assets. As Frimston and colleagues state, Hague 35:provides a framework upon which those concerned with securing the rights of some of the most vulnerable in societies around the world can build to ensure that they do not slip between the cracks of different jurisdictions, and it provides a starting point to bring about the effective cross-border acceptance of at least some forms of anticipatory measures across borders. (para 10.08)Both the books that form the subject of this review are concerned with these overlapping areas of law—what to do when someone becomes incapacitated and requires help or assistance managing their property or personal affairs. A Clinician’s Brief Guide begins, in Chapters 1 and 2,The International Protection of Adults is divided into four parts and begins, in Part I,Each book is divided into chapters or parts that deal with specific aspects of the relevant legal areas that form the basis of the discussion. A Clinician’s Brief Guide is, as is evident from its title, geared towards providing a basic overview of the provisions of the 2005 Act for clinicians and social work practitioners, while The International Protection of Adults provides an in-depth manual of this area for legal practitioners. As such, neither book has a central analysis or argument. In the light of this, this review will draw out the positive and negative aspects of each book, as well as highlighting some interesting dimensions that are raised in them. In particular, it is noteworthy that each book raises issues that have, so far, generally been confined to academic debate. This highlights the fact that the debates on mental capacity law that have thus far been predominantly confined to academia must be taken seriously on a practical level.Both books are clearly aimed at practitioners—The International Protection of Adults that the United Nations Conventions on the Rights of Persons with Disabilities (UNCRPD) is becoming increasingly important.With regards to the practical implications of largely academic debates on mental capacity law, it is frequently noted in The International Protection of Adults (para 3.35), and thus presents a welcome scepticism of the UNCRPD’s solely supported decision-making vision for mental capacity law and adult protection. Frimston and colleagues also suggest that there is a clear distinction between ‘legal’ capacity and ‘mental’ capacity (para 1.09). This is particularly salient because Article 12 is, in fact, focused on ensuring that people with disabilities are guaranteed the same right to legal capacity, which does not automatically bar a finding of mental incapacity. This debate has, to date, manifested itself more within the realms of academic discussion as to how compliant the 2005 Act, for example, is with the UNCRPD.A Clinician’s Brief Guide. This might indicate that while lawyers may be attuned to the issues that the UNCRPD raises in relation to mental capacity law, clinicians and social workers may not be and international human rights law may be far removed from their daily practices.This argument is also noted in HM v Switzerland,Nielsen v Denmark,even where an adult is considered … to lack the ability to take their own decisions, one of the most important trends over the past half-century in both common and civil law jurisdictions has been away from the model of treating them as ‘big children’ and towards seeking … to recognize and promote their autonomy. (para 7.28)Frimston and colleagues also note that the drafters of Hague 35 took as their basis the Hague Conventions for the protection of children (Hague 28 and Hague 34) . This approach to adult safeguarding, drawing on similar measures for the protection of children, is familiar in other contexts, such as European Convention on Human Rights jurisprudence. In The broader comparative benefits and drawbacks of this approach, both practically and theoretically, under Hague 35 may well be a fruitful area for future research.A Clinician’s Brief Guide. On page 30, Brindle and colleagues state that ‘the threshold for determining whether someone lacks capacity depends, in part, on the consequences of the decision and the resulting harm to that person’. Similarly, in The International Protection of Adults it is said that ‘if an individual repeatedly makes unwise decisions then a higher capacity assessment threshold applies’ (para 11.53). It is arguable that the terminology in section 1(4) of the 2005 Act itself, ‘A person is not to be treated as unable to make a decision merely because he makes an unwise decision’, allows for the consequences of a decision to be one of the features that capacity assessors take into consideration when assessing whether someone lacks capacity,sole reason that a person is deemed to lack capacity. Although David Gibson has highlighted this tension behind the capacity assessment process under the Mental Capacity Act,This recognition of academic debate can also be found, on occasions, in A Clinician’s Brief Guide is clearly written, particularly Chapter 7 on the notoriously complicated area of the Deprivation of Liberty Safeguards, there are a number of oversights. One is the operation and application of the offence of wilful neglect or ill treatment in section 44 of the 2005 Act. This oversight is particularly noticeable given that there is now a generalised offence of this nature,is accurate to state that it is not possible for best interests assessors to consent to marriage or sexual relations in the best interests of someone who lacks capacity to do these things,lack capacity under the Act to consent to sexual relations or marriage.The International Protection of Adults also has its weaknesses. One of these is the amount of information covered and its breadth. This is apparent throughout the book but is particularly noticeable in Part I, which deals with the substance and elements of private international law, and Part II, which provides a full overview of all the provisions contained within and the operation of Hague 35. Because of this, readers unfamiliar with private international law as a discipline and its associated terminology may find these section dense and difficult to follow and digest, despite Frimston and colleagues’ attempts to provide definitions. They do provide case examples later in the book,Despite these points of interest, neither book is without its flaws. While The International Protection of Adults, for example, will be of use to anybody wanting a more in-depth analysis of a particular jurisdiction’s provisions for mental incapacity, as well as those who want detailed information about such cross-border issues as is covered by the provisions contained in Hague 35, while A Clinician’s Brief Guide will be useful for anyone unfamiliar with this area of law and who wants a clearly written and basic overview of the provisions of the Mental Capacity Act 2005.Nevertheless, both books have much to commend them to audiences from medical, social work, and legal disciplines.