Hepatitis A virus immunoglobulin M (HAV-IgM) is often used to diagnose acute hepatitis A virus (HAV) infection serologically. However, false-positive test results can interfere with the diagnosis. A 56-year-old woman was readmitted to the hospital owing to abnormal liver function tests for the last 18 months. She had been diagnosed with acute HAV and was hospitalized in isolation based on a positive HAV-IgM test 18 months ago. Regular follow-up after discharge showed abnormal liver function and an elevated level of antinuclear antibodies and immunoglobulin G. For the last 15 days, the patient had fatigue, decreased appetite, and yellow urine, signaling recrudescence. Liver function tests were also abnormal. Liver biopsy revealed histological changes consistent with typical autoimmune hepatitis. After 2 months of methylprednisolone treatment, liver function returned to normal, and HAV-IgM turned negative. The diagnosis of acute HAV in nonendemic areas requires a comprehensive analysis of epidemic history, clinical characteristics, etiology, etc. Therefore, physicians depend on the serum marker for the diagnosis of active infection. However, an increased number of false-positive test results can lead to misdiagnosis and incorrect treatment. Relying solely on this test result further compounds the problem. Many healthcare professionals are still unaware of this issue. False-positive IgM results can occur with any pathogen. We report a case of HAV-IgM with persistently abnormal liver function tests that lasted for 18 months. The patient was incorrectly diagnosed with acute hepatitis A and, finally, with autoimmune hepatitis (AIH).2A 56-year-old woman was readmitted to the hospital with abnormal liver function tests, persisting for the last 18 months. Her hepatic markers were as follows, tested 18 months ago: alanine aminotransferase (ALT) 113 U/L, aspartate aminotransferase (AST) 104 U/L, alkaline phosphatase (ALP) 124 U/L, and glutamate aminotransferase (GGT) 78 U/L. This was attributed to a positive HAV-IgM . She was diagnosed with acute hepatitis A and hospitalized in isolation for treatment. Abnormal symptoms, such as fever, fatigue, abdominal pain, or yellow urine, were not observed. She was treated with glutathione 0.9 g and glycyrrhetinic acid 150 mg/day for 45 days. The liver function recovered, and the markers were as follows: ALT 56 U/L, AST 43 U/L, ALP 109 U/L, and GGT 65 U/L. However, HAV-IgM was still positive. During this time, anti-nuclear antibodies (ANA) 47 U/L  were also detected. Tests for antimitochondrial antibodies (AMAs) and anti-liver kidney microsomal (LKM) antibodies, and anti-smooth muscle antibodies (SMAs) were negative. The immunoglobulin G (IgG) level was 18.3 g/L  and the IgM level was 2.71 g/L . Following discharge, regular monthly reexamination showed abnormal liver function with repeated fluctuations . The patEthics statement: Ethics Statement is not applicable for the case report according to the Medical Ethics Committee of the Third Hospital of Zhenjiang Affiliated Jiangsu University, but Informed consent was obtained from the patient for publication of this case report and accompanying images. The study was conducted in accordance with the Declaration of Helsinki.3HAV is a globally prevalent infectious agent causing intestinal disease. It is mainly transmitted by the fecal-oral route, usually developing as an acute infection followed by self-recovery . HAV-IgMThe HAV vaccine was included in China’s immunization program from 2008. With the universal vaccination of children, the reported incidence of HAV in China has decreased significantly, from 7.34/100,000 in 2004 to 1.66/100,000 in 2015, thus indicating that the prevalence of HAV has been controlled . TestingThe false-positive IgM mechanism is complex and is the result of comprehensive factors, such as polyclonal B cell activation ,12, vigoAlthough a false-positive HAV-IgM should be common in areas where hepatitis A has been controlled, there is a lack of sizeable data based on population surveys. Our search on PubMed, EMBAS, Web of science, and other databases, using the keywords “False-positive HAV-IgM,” or “False-positive hepatitis A IgM,” revealed a total of 3 cases, with a false-positive HAV-IgM and related conditions ,29,30. TFalse positives for IgM usually occur under three circumstances. First, diseases with similar clinical presentation, such as infectious mononucleosis, CMV infection, EBV infection, human immunodeficiency virus infection ,19,20, rSecondly, when there is an overlap with the etiology of other diseases. Finally, IgM positivity with no corresponding clinical symptoms, biochemical indicators, or histological evidence.False-positive IgM results can lead to a disproportionate response in the prevention and control of infectious disease, thus delaying the treatment of the original disease. This patient was diagnosed with acute HAV, and this attracted the attention of the disease control department. The residence was disinfected, and the patient was forcibly hospitalized in isolation. This inconvenienced both, her work and her life, in addition to mental trauma. Simultaneously, the treatment of AIH was also delayed to a certain extent. The same confusion was seen in other case reports. A 76-year-old woman with congestive heart failure was diagnosed as having HAV by a community doctor in view of a positive HAV-IgM test, which resulted in her being barred from living in the community . False-pTherefore, even though a positive HAV-IgM test forms the basis for the diagnosis of acute HAV, it should not be accepted as the only confirmatory test, especially when results persist, the patient’s condition is severe enough to require hospitalization, or when there are no epidemiological findings. Instead, wherever possible, the diagnosis should be confirmed by other means.


Background: Coronavirus Diesease-2019 (COVID-19) outbreak has led to the suspension of the activities of dental schools. Therefore, reorganizing clinical settings and supporting services as quickly as possible has received much attention to reopen dental schools. The present study aimed to evaluate the applicability of the Intervention Mapping (IM) approach for designing, implementing, and evaluating an intervention program to prevent and control COVID-19 in dental schools.Methods: Following the IM protocol, six steps were completed in the planning and development of an intervention, targeting, and management of Dental School during the COVID-19 pandemic.Results: The information obtained from the needs assessment revealed that the COVID-19 outbreak prevention was associated with the use of personal protective equipment by all target groups, infection control measures taken in the environment, preparation of the environment and equipment, changes in the treatment plan according to the COVID-19 pandemic, changing the admission process of patients, and reduction of attendance of target groups in the school are linked with. In this study, determinant factors affecting the COVID-19 prevention at the individual level were identified based on the Protection Motivation Theory (PMT). In this program, various methods, such as presentation of information, modeling role, and persuasion measures, were utilized and the practical programs included educational films and group discussions implemented.Conclusions: Our findings indicated that intervention in dental environments on the basis of the IM process can develop a comprehensive and structured program in the dental school and hence can reduce the risk of the COVID-19 infection. In recent months, the high prevalence of the new coronavirus disease-2019 (COVID-19) is considered an international public health concern (Due to the high transmissibility of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), close contact between the patients and dentists, nature of dental procedures , 4, and The activities of dental schools have been resumed by imposing some restrictions from June 21, 2020 in Iran due to the educational needs of students and the medical needs of patients. Given the vast number of patients and their close contact with students, teachers, and staff in the dental schools, some managerial, educational, and environmental interventions are necessary to be implemented for the protection of all stockholders. To reopen the schools, it is required to provide immediate educational, clinical, and support services .The Centers for Disease Control and Prevention (CDC), American Dental Association (ADA), and WHO have provided some effective practical guidelines for controlling the prevalence of COVID-19 in dental settings . HoweverIt is a protocol that helps to design multilevel health promotion interventions and selects appropriate implementation strategies . IM consStep 1: Conducting needs assessmentStep 2: Specifying change objectivesStep 3: Selecting theory-based methods and practical strategiesStep 4: Developing program componentsStep 5: Specifying implementationStep 6: Generating evaluation plan .Steps 1–4 focus on the presentation of multilevel interventions for improving health behaviors and environmental conditions.In the first step of IM, planners evaluate assets and needs.At this stage, all representatives, such as executives and those who are responsible for protecting the intervention, were involved in the program to determine required measures for implementing the program and identifying determinants (obstacles and facilitators). To involve patients in the program, a committee called the COVID-19 Prevention Committee at the School of Dentistry (CPDS) was formed on May 21, 2020. The members of this committee consist of the representatives of the students, the chairman of the infection control committee of the school, representative of the university teachers, staff representative, manager of the nursing office, patient representative, an IT official of the school, representative of the department of financial and administrative affairs of the school, the head of public affairs, the dean of the school, and some SHS2020 standard company's representatives. The recognized stakeholders were in both individual and environmental levels. The team manager (Head of the School) determined the responsibilities of each team member and the decision-making structure. During this session, the members of the three teams, namely, education, infection control, and logistics, were separately assigned for performing relevant activities.To assign all actors, barriers, and potential facilitators of implementing the intervention, it was necessary to conduct a needs assessment. For this reason, the brainstorming method was used in CPDS, and the results of the previous regular evaluation that have already been conducted in the school were applied. Moreover, the environmental conditions were observed and evaluated.At this point, social, epidemiological, and behavioral-environmental analyses were performed. The needs assessment of the present study was focused on the school as the target group, such as teachers, students, staff , and patients. This entailed a review of literature on determinants and factors associated with the prevalence of COVID-19 in dental settings and the role of behaviorally and environmentally predetermined risk factors in the rise of the prevalence of COVID-19 and its determinants. The committee used the experimental data, theoretical references, and collected new data  to prepare a list of behavioral and environmental risk factors affecting the spread of COVID-19 and its determinants. In this phase, recognition of the school capabilities was achieved.At this stage, CPDS identified the expected changes in the behavioral and environmental factors, which were already determined in the needs assessment stage. The prioritization of behavioral and environmental consequences was performed according to their importance and variability by literature review and the consensus between the members of the CPDS committee. Afterward, functional objectives were determined for each behavioral and environmental consequence and their determinants, and a matrix of change objectives was plotted for each program level. We used brainstorming, a review of literature, and constructs of health promotion theories to identify the determinants.In this step of CPDS, the brainstorming method and literature review were used to identify the appropriate methods and strategies affecting the determinants in step 2. During this process, a summary of the theoretical methods proposed by Bartholomew et al. was applied . SpecialIn this step, the intervention content was proposed by the CPDS team, and the protocols of implementation, activities, and training materials were produced. The cultural adaptation of these programs was conducted through consultation with the program stakeholders. Then, the scope, sequence, communication channels, themes, and a list of required materials were provided and documented. Meanwhile, a review of the existing training materials was performed to determine whether the training materials have already been consistent with the objectives of this program or not. Afterward, the required training materials were produced and pre-tested.At this step, the potential adopters and implementers of the program were identified. A review of the transplantation system (CPDS) was also performed. Then, the functional objectives of adoption, implementation , and program survival were identified. In the next stage, the determinants of adoption, implementation, and survival of the program were determined using the brainstorming method and literature review. Based on the importance and variability, the prioritization of the change objectives was conducted. Then, appropriate methods and strategies affecting the determinants of adoption, implementation, and survival of the program were selected, and the intervention was designed and developed to use the program.In the final stage of IM, a plan was provided by the planners to evaluate the effectiveness and quality of the intervention . In the A checklist was designed for the evaluation of behavioral and environmental factors, performance objectives, determinants, and change objectives. A checklist was also designed for the process evaluation. Evaluation indicators and criteria were determined, and the evaluation plan was documented. To evaluate the program, the context, input, process, and product (CIPP) evaluation checklist was utilized . The evaThe protocol of this study was approved by the Ethics Committee of the Hamadan University of Medical Sciences . The questionnaire was anonymous, and informed consent was obtained from the participants in the survey. Participation in the study was voluntary.As of May 21, 2020, a total of 129,341 cases with COVID-19 have been laboratory confirmed and 7,249 deaths diagnosed ; and theOne of the key points in the control of infectious disease epidemics is designing interventions to emphasize the simultaneous increase of perceived fear and threat and perceived efficacy  for disease prevention and self-efficacy. Therefore, Protection Motivation Theory (PMT) was used to better understand the performance of preventive behaviors at an individual level .A high commitment of management to implement the intervention, high level of staff education, access to new device/equipment, sufficient budget, sufficient workforce to implement the intervention, and presence of qualified professors in the field of infection control were among the strengths of the faculty.Based on the information obtained from the needs assessment stage, two objectives of the program  were considered to prevent the spread of the COVID-19. For the target group, such as students and professors, the program was defined at the individual level as the use of appropriate personal protective equipment and suitable treatment measures to prevent the spread of COVID-19 .In the target group of administrative staff and patients, the implementation of the preventive behaviors to prevent the transmission and spread of COVID-19 was considered as the program objective at the individual level.Due to the important role of the medical staff and service personnel in infection control, the use of appropriate personal protective equipment and precise infection control measures among them was considered at the individual level in addition to the other staff.In addition, the objectives of the program for environmental factors were to prepare the environment and equipment, change the system of queuing and admission of patients, and reduce the capacity of target groups in the faculty. According to the program objectives, performance objectives were defined at the individual level for students, professors, administrative staff, medical staff, and patients, and the performance objectives were defined at the environmental level for providers .After identifying the functional objectives, the important and changeable determinants of these objectives were selected for each level based on the results of the IM phase. For the individual level, PMT was selected as a framework for describing factors in relation to preventive behaviors of COVID-19 . AnotherFinally, for providers  at the environmental level, the knowledge of the latest COVID-19 prevention guidelines in dental settings, barriers, attitudes, and outcome expectations were chosen as determinants. Next, the matrix of change objectives, which is derived from the intersection of performance objectives with determinants, was formed for each level of intervention .These performance objectives have been developed based on the protocols of the WHO, CDC, and the Ministry of Health and Medical Education of Iran –11.To reduce the presence of target groups in the school, contact-less treatment and remote learning were considered. This intervention was performed by using a telephone or online appointment system, teledentistry, implementation of virtual teaching, phone or online screening of patients, and installation of the Picture Archiving and Communication Systems software (PACS). The patient screening was conducted through a telephone call or appointment system so that before making an appointment, the patient was asked to complete the COVD-19 screening. After completing the screening form, if he/she was not identified as a high-risk case, was referred to oral diseases resident to do teledentistry. At this level, patients would express their symptoms and problems, and then if necessary, would send a photograph of their mouth to the oral diseases resident. The resident determines whether the person needs essential or urgent treatment or not based on the patient history and the provided photograph. An appointment was considered for the patients who need special treatments.Virtual teaching was considered for theoretical courses. Adobe connect platform was considered for theoretical courses and webinar.The installation of PACS software, which reduces paper records, increases the speed and accuracy of diagnoses and subsequently reduces the patient waiting time and their contact with staff, students, and faculty in the department. The PACS software could increase the speed and accuracy of diagnoses and subsequently reduce the patient waiting time and their contact with staff, students and faculty in the department.At this stage, all the change objectives were organized by the relevant determinants, and the methods of each category of the objectives were identified through the brainstorming method. Afterward, a theoretical and experimental review was performed to identify the appropriate methods and strategies for changing determinants.The strategy planning team determined the strategies in two ways, such as  brainstoIn this step, a final intervention framework was produced for implementation. Based on the needs assessment data and the additional focus group discussion with the target group, to collect the data regarding intervention material preferences, the planning team provided a list of intervention materials and activities. In practical, in this intervention, the COVID-19 instructions recommended by Iran's Ministry of Health and the instructions in relation to infection control were considered , ward managers, infection control team of the school, and the representatives of SHS2020 standard.Then, the executive team was informed about the methods and strategies for implementation of the intervention in different target groups and the tasks of the designated teams in detail.The instructions of the Ministry of Health were also provided for the executors.Context, Input, Process, and Product evaluation checklist was used to evaluate the program . This chContext, Input, Process, and Product components were selectively used in different sequences and generally at the same time depending on the need for specific evaluations . In thisEvaluation in this study encompassed the following steps:1. Contractual agreements: A clear understanding of the evaluation that needs to be conducted was established.2. Assessing the conditions and programming context: The needs, strengths and weaknesses, threats, opportunities, and problems in the faculty environment were assessed and evaluated. This step was consistent with the needs assessment phase and performed concurrently with this phase.3. Evaluation of the program inputs: Existing strategies and programs, capacity and feasibility of the designed program, evaluation of budget and equipment, tools, and materials required to conduct the program were assessed and evaluated. This step was also performed with the needs assessment phase.4. Evaluation of the program processes: Monitoring, documentation, and evaluation of the program activities were performed, and representatives of SHS2020 standard were involved in monitoring, observation, preserving photographic records, and providing periodic progress reports on the program implementation. At this stage, the checklists were prepared and completed by the standard representatives through observation. By photography and preparing a report regarding the documentation and intervention processes and the periodic progress reports to the faculty officials, they were informed of the program process. This time, it was determined whether all the modules of the program have been implemented? Does the program run according to the predetermined sequences and strategies? Did all the target groups receive the program? To what extent are the targets groups have involved in the program? Is the predetermined performance objective accomplished?The satisfaction of the target groups related to the intervention was also questioned.5. Evaluation of the program consequences: The information about the acceptance, modification, or rejection of the program was evaluated by asking from the target groups. The outcomes of this program included: increasing knowledge, perceived threat, perceived efficiency, reducing barriers to understanding, and increasing preventive behaviors against COVID-19 infection, which is obtained through completing the PMT questionnaire by staff, faculty, and students before and after the intervention.6. Evaluation of the effectiveness of program: The results of the quality and importance of the program must be evaluated. In this regard, the effectiveness of the interventions will be evaluated by the number of involved cases in dental school related to therapeutic and educational processes 3 months after the intervention. After performing above six evaluation steps by the representatives of BRSM Company and providing a report on the observance of applicable professional standards to the faculty officials, the identified defects were fixed. Moreover, the head office of the BRSM Company was invited to refer to the faculty for the final evaluation of the program. After conducting the final evaluations by the faculty, the evaluators of this company, on 28 June, 2020, considered the faculty to be eligible for the SHS2020 standard certification .7. Sustainability evaluation: This stage that will be carried out by BRSM Company 6 months after the initial evaluation, it will be determined to what extent the program has been successfully institutionalized and will continue over time.8. The final synthesis report: Consistent reports of evaluation findings were collected and communicated to the faculty stakeholders. Reports on the program background, implementation, and results of the program were presented to a wide range of audiences, and they were informed of the interventions carried out and the results of the evaluation by BRSM.The present study describes the process design, content, and evaluation of COVID-19 preventive intervention in dental schools. This study for the first time provides practical and simple guidelines for reopening dental schools and providing dental services during the COVID-19 epidemic. Due to the lack of a global protocol for dental services during this pandemic, dental services have been partially or completely disrupted in many countries. In this regard, the lack of standard protocols can increase the prevalence of COVID-19 in dental health centers.While some national health institutions, such as the NHS, have provided guidance and advice for managing clinical dental emergencies during epidemics . This inIn this study, IM was used as a conceptual framework for the intervention design. Although the design of the intervention was a time-consuming process, it can lead to the implementation of the intervention with a systematic and evidence-based approach.The Centers for Disease Control and Prevention, ADA, and WHO provided some recommendations for the control of the prevalence of COVID-19 for dentists and dental staff, such as patient screening, infection control , behavioral measures , and treatment measures  .The first essential step for the safe management of patients during the pandemic is investigating risk level of patient through screening patients to cut the transmission chain and evaluating the chief complaint of the patients . These cThe most important measures to control the infection included selecting one person to supply the disinfectants for surfaces, equipment, and tools. At the beginning of each day, this person prepared the appropriate disinfectants for the surfaces, equipment, and tools according to the standard protocol and provided them for the medical staff in different wards. Isolation of well-ventilated dental chair unit  was conducted as another important measure of infection control .Fear arousal strategy as behaviors that protect people against life-threatening conditions (such as COVID-19) is often used as an effective way to promote health, prevent disease, and adopt healthy behaviors in society . HoweverStaff training was also conducted in small groups in large spaces with proper ventilation.In the present study, the intervention was designed based on the latest scientific findings in the field of COVID-19 as another important measure. Therefore, a scientific research team was formed to access the latest scientific findings through searching and then inform the planning team every 72 h. The planning team examines the received information scientifically, evaluates their compliance with the facilities and policies of the organization, makes the necessary changes in the program, and informs the project implementers. However, finding a balance between previous and new findings and constantly updating the information regarding the transmission and prevention ways of COVID-19 are still challenges, especially in dentistry.This study had some limitations at the time of implementation of the intervention. These limitations were related to insufficient scientific information about the nature of the virus like its transmission modes, and incubation time, and due to constant updating information, the effectiveness of the preventive methods remains a challenge.This study describes the performance of the Iranian School of Dentistry in developing disease prevention strategies during the COVID-19 pandemic based on the IM process. Our findings indicated that the intervention in dental settings based on the IM process leads to a comprehensive and structured program in dental schools. Therefore, the teamwork can consider the necessary changes in the running programs as the global and national guidelines for the epidemic change. Therefore, it can be concluded that intervention in dental environments based on the IM process can develop a comprehensive and structured program in the dental school.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.The studies involving human participants were reviewed and approved by the Hamadan University of Medical Sciences Ethics Committee . This study and the method of obtaining consent were approved by the Ethics Committee. The questionnaire was anonymous and informed consent was considered as agreeing to participate in the survey. Participation in the study was voluntary. The patients/participants provided their written informed consent to participate in this study.AM, SS, SB, NR, AH, MM, HK, and OA contributed to the study concept and design. SS, NR, BB, OA, and AP contributed to the acquisition of data. SS, MM, and AP contributed to the initial drafting of the manuscript. SS, AM, AH, and SB contributed to study supervision. All authors contributed to the interpretation of data and critical revision of the report.We acknowledge funding from the Hamadan University of Medical Sciences (9905283448).The content is solely the responsibility of the authors.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background. Continuing assessment of the quality of evaluation programs promotes the quality of exams and ensures learners’ accurate evaluation. This study aimed to examine the quality of the competency-based evaluation program for dentistry based on the context, input, process, and product (CIPP) model.Methods. In a mixed-methods study , dentistry students’ evaluation program using competency-based assessment methods was examined by dentistry professors based on the CIPP model and via a reliable and valid researcher-made questionnaire. The questionnaire had three sections on demographic information, evaluation questions, and open-ended questions. Descriptive statistics (mean and SD) were used to analyze the questionnaire items. Open-ended questions were analyzed by content analysis, and the quantitative part was analyzed using SPSS.Results. Twenty-five faculty members from the departments of orthodontics and dental prosthesis completed the questionnaires. The overall level of faculty members’ satisfaction with the new evaluation program was above average (54±17.02). They had the highest degree of satisfaction with output indices and the lowest degree with input indices. The analysis of the open-ended questions yielded two general categories of "providing the human and physical infrastructure" and "spiritual support and encouragement of educational innovation."Conclusion. The competency-based evaluation program needs the support of managers and planners. The faculty should provide the infrastructure for the implementation of these methods. By meeting the requirements, the professors will be motivated to implement these methods, and the paradigm can shift from traditional to novel evaluation methods. In the dimension of context, the needs, goals, and conditions of achieving the program outputs are evaluated.4 In the dimension of input, all the factors affecting the achievement of educational goals, such as human resources, financial sources, strategies, and the program execution timetable, are evaluated.4 With this dimension, one can examine various solutions to realize educational goals and prevent using unnecessary facilities for achieving these goals.5 In the dimension of process, the program execution flow in the real world and its compatibility with the pre-determined goals and timetable are evaluated. Finally, in the dimension of output, the effectiveness and efficiency of the program in achieving the pre-determined goals are evaluated.4 The results of the evaluation provide authorities and decision-makers with information about continuing or aborting the program.6 In various departments of dentistry, educational programs have been evaluated based on the CIPP model. For instance, in a study by Tabari, the realization of educational goals was evaluated in three departments of operative dentistry, pediatric dentistry, and orthodontics. Based on this model, Babol University of Medical Sciences had realized its educational goals at an optimal level.7 According to Pakdaman et al, the realization of educational goals based on CIPP in the periodontics and oral health department requires revision in two input and process dimensions.8 In the study by Makarem et al in Mashhad Dental School, the educational program of the department of oral health needs revisions in the domain of process based on the CIPP model.9 Based on the evaluation of the dentistry program at the University of Birmingham, the dentistry students had poor capabilities in terms of root canal treatment and were not quite familiar with the equipment and techniques of this discipline.10 Henzi et al11 in the United States also evaluated dentistry educational programs from the learners’ viewpoint in some departments and identified the problematic areas. Student evaluation is an integral part of educational programs. In the Faculty of Dentistry, Tabriz University of Medical Sciences (Iran), modifications have been made to the dentistry evaluation program in line with a reform plan, and competency-based assessment methods have replaced traditional methods that relied on multiple-choice tests and professors’ opinions. The review of the literature showed that the evaluation program of dentistry using a competency-based approach has not been evaluated yet. Therefore, this study aimed to assess the dentistry competency-based evaluation program based on the comprehensive CIPP model to identify the strong and weak points of the program and provide insights for planners to promote the quality of exams.Continuing program evaluation and identifying its strong and weak points are essential to having an efficient educational system.The data in the present mixed-methods  study were collected via a reliable and valid researcher-made questionnaire based on the CIPP model and open-ended questions, with the professors’ voluntary participation Departments of Orthodontics and Prosthodontics, Faculty of Dentistry, Tabriz University of Medical Sciences.This study was conducted in three stages.Stage 1 consisted of designing and extracting the evaluation questions of the “implementation of professional competency-based evaluation program based on the CIPP model” in four dimensions of context, input, process, and output. Stage 2 involved a review by an expert panel to determine the content and face validity indices of the instrument. Stage 3, as a pilot study, evaluated the dentistry evaluation program in the two departments of orthodontics and prosthodontics, Faculty of Dentistry, Tabriz University of Medical Sciences, based on reliable and valid researcher-made instruments.very low, low, moderate, high, and very high). At the end of these items, some open-ended questions asked the participants to recommend methods for facilitating novel learner evaluation programs for the general dentistry program.In this step, the questions were designed based on the CIPP model in the four domains. There were six items in the domain of context, six in input, six in process, and seven in output. The items were scored on a five-point Likert scale , the method introduced by Waltz and Bausell was adopted, and the judgment of each member of the expert panel about each item was checked by three criteria of simplicity, clarity, and relevance on a four-point Likert scale. The minimum acceptable value for CVI, based on the expert panel size (n = 8), was 0.79, and if the CVI of an item was < 0.79, it was modified based on the experts’ opinion.It is essential, 2 = It is useful but not essential, 3 = It is not essential. Based on Lawshe’s table and the number of evaluators (n = 8), items whose CVR was > 0.75 were deemed essential.13To determine the content validity ratio (CVR), each member of the expert panel’s judgment about each item was evaluated on a three-point scale: 1 = not important at all) to five (very important). Only items with scores > 1.5 were deemed as having acceptable face validity.To examine face validity, the participants were asked to check the degree of importance of each item on a five-point Likert scale from 1  in SPSS 19. Open-ended questions were analyzed by content analysis. In this analysis, sentences with semantic content were highlighted; their semantic content was extracted and coded, and similar codes were subsumed under categories.The content and face validity of the tools were assessed by CVI, CVR, and the item impact score by seeking assistance from eight faculty members. The reliability of the tools was measured by Cronbach’s alpha. The content and face validity and the reliability of the program evaluation tool for the “implementation of novel clinical skills’ evaluation methods” from the viewpoint of dentistry faculty members based on the CIPP model were estimated and confirmed at CVR = 0.89, CVI = 0.92, and α = 0.76.Twenty-five faculty members of the departments mentioned above completed the questionnaires. The participants’ level of satisfaction with the context indices in the professional competency-based evaluation program was examined in two domains of “contextual factors related to the educational institution” and “contextual factors related to human resources.” The general level of satisfaction with the context indices was above average (55%). The highest satisfaction level belonged to the “compatibility of the department’s educational atmosphere for implementing novel evaluation methods” and “novel methods’ acceptance by and attraction for the students.” In contrast, the lowest satisfaction level belonged to the “physical compatibility of the department for administering the exams” .The participants’ satisfaction with input indices in the professional competency-based evaluation program was examined in three domains of “physical infrastructure of the faculty,” “human infrastructure,” and “professor empowerment.” The general satisfaction with input indices was below average (48%). The highest degree of satisfaction belonged to the “physical infrastructure of the faculty.” The participants had the highest level of satisfaction with the “quality of the designed evaluation instruments” and the “effect of content familiarity workshops to familiarize the faculty members with competency-based assessment methods,” while they had the lowest level of satisfaction with the “professors’ familiarity and mastery” .The participants’ level of satisfaction with the process indices of the evaluation program was examined in two domains of “design and implementation of performance-based evaluation methods” and “feedbacks on the implementation of performance-based evaluation programs.” The general level of satisfaction with process indices was above average (55%). The highest satisfaction level belonged to “cooperation between faculty members in implementing performance-based assessment methods” and “cooperation in designing clinical skills’ evaluation methods.” The lowest degree of satisfaction belonged to “receiving feedback from students to promote performance-based evaluation methods” .The participants’ satisfaction with the output of implementing performance-based evaluation methods was examined in three domains of “teaching and learning outcomes,” “promotion of professional and academic ethics,” and “implementation of the educational curriculum.” The general satisfaction level of faculty members with the outputs of performance-based evaluation methods was above average (58%). The highest degree of satisfaction belonged to “teaching and learning outcomes,” and more specifically, with “application of performance-based evaluation methods in teaching the practical and clinical aspects of the discipline” and “application of novel evaluation methods in forming learners’ learning experiences.” The lowest level of satisfaction belonged to the “application of performance-based evaluation methods in promoting professional ethics for learners” .The faculty members’ general satisfaction level was the highest with output indices and the lowest with the input indices .The analysis of open-ended questions yielded two general categories of “providing the human and physical infrastructure” and “spiritual support and encouragement of educational innovation.”In “providing the human and physical infrastructure,” two sub-categories of “dentistry professors’ empowerment” and “preparing physical facilities” were obtained.The empowerment of human resources is the driving force for changing the educational system. To bring about a paradigm shift from traditional educational methods to novel evaluation methods, human resources should be prepared for accepting such a change. The university should design professor empowerment courses based on the timetable. A participant from the Department of Prosthodontics said, “It is better to hold short but continuous and practical empowerment courses in the faculty. We don’t need theoretical concepts but workshops and practice. This is the best method for teaching busy learners.”According to a participant from the Department of Orthodontics, “It’s better to hold a workshop for our discipline on designing checklists and writing scenarios. We attend most workshops with medical professors, where they become the center of attention, and we do not get to see tangible examples.”Preparing the inputs of program implementation is critical for program implementation. A change in assessment methods should be made in the faculty’s strategic plans, and its implementation requires a sufficient budget. “We do not have a test center to design standard stations or administer standard exams,” said a participant from the Department of Periodontics. According to a participant from the Department of Orthodontics, “For this number of students, we have few facilities and professors. We need many professors if we want to design Direct Observation of Procedurals Skills (DOPs) test for students, pay attention to the accurate implementation of procedures by the learners during the course, and ensure their authentic learning.”In the category of “spiritual support and encouragement of educational innovation,” two sub-categories of “promotion of innovative professors” and “valuing educational innovations” were extracted.The promotion system in medical sciences universities is mostly research-based, and educational innovations are not defined in the promotion system or have an insignificant role. Therefore, professors prefer to publish scientific articles in ISI-index journals and get promoted instead of innovating educational activities that are not reflected anywhere and do not lead to promotion.A participant from the Department of Orthodontics said, “If we want innovation in education, we must change the promotion regulations. Educational and research faculty members are viewed as being the same in Iran. The university’s policy determines the professors’ performance.”According to a participant from the Department of Periodontics, “The mission of the university should change towards innovation in education, and we should move in this direction. A change in our attitude towards education and evaluation needs a change in the university’s attitudes and regulations.”Educational innovations have not found their proper place in medical sciences universities, and professors come up with such innovations merely based on their personal interests. If the university modifies its values towards a student-centered approach and recruits innovative professors, it can motivate the professors to bring about changes and value the services of creative professors instead of regarding them as rebels who cause trouble for other professors.A participant from the Department of Periodontics commented, “Other professors think novel evaluation and teaching methods are an extra burden, maybe because they receive no feedback from the Dean of the Faculty. If our feedback system is functional, positive feedback will serve as spiritual support, which encourages other professors to cooperate in the implementation of novel methods.”According to a participant from the Department of Orthodontics, “Sometimes we don’t even receive written positive feedback, so we lose interest over time. The universities think a professor who gives only one final score to learners based on observing their performance over the semester is the same as one who designs DOPs forms and writes scenarios. That is why innovative professors become de-motivated.”14 professors and students at Ardakan University (Iran) believed that the resources and equipment were not optimal. Based on studies on dental schools in Tehran and Babol University of Medical Sciences, the equipment of periodontics and oral health departments was insufficient.15 Of course, the fact that these evaluation methods are new might explain the lack of sufficient equipment for administering these exams. Also, professors have not yet mastered the design and implementation of such exams. The participants mentioned in open-ended questions that there is no separate professor empowerment course for dentistry; therefore, they do not become familiar with objective scenarios appropriate for their discipline and test design techniques in the existing educational workshops. They believed that it would be better to hold workshops in the Faculty of Dentistry and between the class times so that they could participate in them. In the study by Makarem et al,9 a major problem in educational inputs of oral health and social dentistry was professors’ insufficient skills and education. Another problem was the students’ lack of awareness. The use of novel evaluation methods without raising the learners’ awareness leads to stress and confusion in their studies.16 Compared to written exams and multiple-choice tests, novel evaluation methods are stressful for students. According to Zartman et al,17 in dentistry, performance examination increases learners’ hand tremors and changes their voice; in some cases, these have prevented the learner from taking the exam. In a study by Hassell18 on rheumatology, the OSCE  exam caused excessive stress in learners.Unfamiliarity with these exams can exacerbate this stress. Various studies have shown that the expression of expectations from the learners and the evaluation method at the beginning of each course directs the learners’ method of learning and studying.19 In the study by Makarem et al, vague objectives and expectations from learners were a weakness of educational input.9 In the domain of process, the highest satisfaction level was with the cooperation between faculty members in designing and implementing the exams.This study aimed to evaluate the “dentistry competency-based evaluation program” based on the CIPP model from dentistry faculty academic staff members’ viewpoint. The faculty members of periodontics and orthodontics departments exhibited moderate satisfaction with the professional competency-based evaluation program. To promote the quality of exams, the infrastructure should be prepared in all four domains. In terms of context, the faculty members believed that the university does not provide a supportive context for the implementation of performance-based evaluation methods, and the physical facilities of the department are not suitable. Still, the atmosphere of the department and the novel methods’ acceptance by and attraction for the students were better compared to the other items. Therefore, faculty members and students are ready to accept novel evaluation methods. In terms of input, faculty members held that the educational facilities of the department are not appropriate. They also declared in open-ended questions that the department does not have an examination room or facilities for administering such tests. Similarly, in a study by Rezapour Mirsaleh et al,20The professors are ready for a paradigm shift from traditional to novel evaluation methods, but they need support and encouragement from the faculty. Professors become de-motivated because they do not receive feedback from the faculty and students. They mentioned in open-ended questions that they do not receive any positive feedback from the faculty, and their innovation does not affect their promotion; the promotion regulation is research-based and does not pay enough attention to educational innovations.21 However, the professors believed that the implementation of these exams was weak in terms of the complete curriculum implementation as it does not provide enough facilities for designing exams based on the capabilities required by the course. Moreover, the professor-to-student ratio is low, and professors cannot evaluate all the capabilities with these methods. In the qualitative study, by examining the educational problems of the school of dentistry, Qazvin University of Medical Sciences, a major challenge was the low professor-to-student ratio in most departments.22 Another reason for the poor performance of these exams in implementing the curriculum of dentistry could be that these exams are new, and professors are still in the first stages of exam design and adaptation to ensure the acquisition of capabilities. The overall results of the evaluation revealed that preparing the infrastructure, internalizing the use of novel evaluation methods, and supporting and encouraging the professors by giving them educational incentives and promotion can help implement these exams.According to the professors, novel evaluation methods help the learners’ practical learning and the formation of their learning experiences. These exams aim to ensure the learners’ mastery of the capabilities required by the course.The results indicated that, according to the faculty academic staff members, the implementation of competence-based evaluation methods in two departments of Periodontics and Orthodontics has infrastructural problems and is far from the standard administration of these exams. Some modifications, such as preparing the standard setting and facilities for administering the exams, empowering the professors, and defining the status of these exams in the curriculum and their role in ensuring the learners’ capabilities can enhance the quality of practical exams to approach the standards of advanced countries.RN, HH, SF, and NB prepared the manuscript. NB was responsible for coordinating the study. RN and SF distributed the questionnaires, coordinated FGDs, and interviewed the participants. RN and HH commented on the coding process and analyzed the questionnaires. HH wrote the first draft of the paper. RN, SF, and NB reviewed the first draft of the paper and improved it. All authors have read and approved the final version of the manuscript.The authors would like to thank Tabriz University of Medical Sciences for supporting and granting this research as a part of an MS thesis in medical education and the dental faculty members who participated in this study.This research was supported and granted by the Medical Education Research Center of Tabriz University of Medical Sciences, Tabriz, Iran. The funder had no responsibility for the design of the study, data collection, analysis, and writing of the manuscript.No competing interests.This study was approved by the Research Ethics Committee of Tabriz University of Medical Sciences (IR.TBZMED.REC.1397.254). Data collection was carried out after obtaining verbal and signed informed consent from the participants following the Deceleration of Helsinki. The informed consent process provided participants the opportunity to ask questions and consider all options. Participants could refuse to participate or withdraw from the study at any time.


Verticillium dahliae (V. dahliae) is a serious disease in cotton, resulting in massive yield losses and decline of fiber quality. Breeding resistant cotton cultivars is an efficient but elaborate method to improve the resistance of cotton against V. dahliae infection. However, the functional mechanism of several excellent VW resistant cotton cultivars is poorly understood at present. In our current study, we carried out RNA-seq to discover the differentially expressed genes (DEGs) in the roots of susceptible cotton Gossypium hirsutum cultivar Junmian 1 (J1) and resistant cotton G.hirsutum cultivar Liaomian 38 (L38) upon Vd991 inoculation at two time points compared with the mock inoculated control plants. The potential function of DEGs uniquely expressed in J1 and L38 was also analyzed by GO enrichment and KEGG pathway associations. Most DEGs were assigned to resistance-related functions. In addition, resistance gene analogues (RGAs) were identified and analyzed for their role in the heightened resistance of the L38 cultivar against the devastating Vd991. In summary, we analyzed the regulatory network of genes in the resistant cotton cultivar L38 during V. dahliae infection, providing a novel and comprehensive insight into VW resistance in cotton.Cotton is an important economic crop worldwide. Verticillium wilt (VW) caused by  R genes include the nucleotide-binding site (NBS), leucine-rich repeat (LRR), serine/threonine protein kinase domain (PK), drosophila toll domain, coiled-coil structure (CC), and transmembrane domain (TM) [Plants are under constant attack from various pests including bacteria, fungi, oomycetes, nematodes, and insects. As plant are unable to escape attacking pathogens by moving to a more favorable environment, they possess efficient defense mechanisms to protect themselves from disease, such as physical barriers and production of antimicrobial compounds ,2. Thus,ain (TM) . Moreoveain (TM) . SA-depeain (TM) .Gossypium spp.) is an important economic crop species cultivated worldwide. Verticillium wilt (VW) of cotton is a serious vascular disease that is detrimental to cotton yield and fiber quality, and is caused by the soil-born fungus Verticillium dahliae (V. dahliae). It is known that V. dahliae attacks host plants through their roots, generally takes around 2–4 days to reach the xylem vessels, and proliferates in the vascular to induce VW [V. dahliae is difficult to control owing to its ability to survive long-term as microsclerotia in the soil and adapt to a broad host range to survive and propagate [R genes [GbaNA1 [GhDSC1 [V. dahliae. Adenosine triphosphate (ATP)-binding cassette (ABC) genes have been identified that play a vital role in cotton against V. dahliae infection [GhOPR9 has been found to be a positive regulator under V. dahliae infection which can modulate the expression of genes related to the JA pathway [V. dahlia [GhWRKY70D13 negatively regulated cotton defense against V. dahliae through regulation of the genes involved in ET and JA biosynthesis and signaling pathways [V. dahlia [V. dahliae by interacting with the chitin sensory receptors [V. dahliae by activating JA biosynthesis and phenylpropanoid pathway [Cotton  and G. hirsutum susceptibility cultivar Junmian No. 1 (J1) response to V. dahliae infection, respectively. The aim of this study was to discover the differentially expressed genes after V. dahliae infection to identify the potential resistant network of L38. The significantly different expressed genes (DEGs) were classified and divided into six groups, including J1-early, J1-late, J1-sustained, L38-early, L38-late, and L38-sustained. The potential function of DEGs in these groups were analyzed and putative association with sectors associated with disease resistant pathways, such as phenylpropanoid biosynthesis, plant hormone signal transduction, Mitogen-activated protein kinase (MAPK) signaling pathway and plant-pathogen interaction were revealed from our study. In addition, the resistance gene analogues (RGAs) that displayed differential expression were further analyzed. Our findings suggest that the expression of several resistance-related genes was induced in the resistant cotton cultivar L38 in a manner different from the susceptible cultivar J1 during V. dahliae infection, thus providing an insight into the genomic networks at play that result in the VW resistance of the L38 cotton cultivar.RNA-seq has been widely applied to monitor the gene expression profiles and describe the response characteristics of cotton roots under nfection ,30,31,32G. hirsutum cultivar Junmian 1 (J1) and resistant cotton G.hirsutum cultivar Liaomian 38 (L38) were grown and maintained in a greenhouse at 28 °C under 16 h light/8 h dark photoperiod. Moreover, L38 and J1 were planted at a disease nursery in Liaoyang, located in northeast of China .The susceptible cotton V. dahliae strain Vd991 [6 conidia/mL which was then used for inoculating cotton seedlings [The highly virulent in Vd991  was culteedlings . Roots oThe disease index (DI) of Verticillium wilt was obtained according to the following formula:The index, comprising five grades , was used for assigning infected plants. Grade 0 indicates that the plant is healthy and has no disease symptoms, grades 1 to 4 represent the typical yellowing and wilting observed in 0–25%, 25–50%, 50–75%, and 75–100% leaves of investigated plants, respectively.Both J1 and L38 root samples were inoculated with Vd991 after 24 h and 72 h, in addition, the samples without inoculation and collected just prior to the treatments were designated as 0 h. For each experiment three technical replicates were performed with each replicate including 6 seedlings. Therefore, a total of 18 root samples were chosen for RNA extraction. Total RNA samples of cotton roots were extracted using Plant RNA Purification Kit . The RNA concentration and purity were measured by NanoDrop 2000 spectrophotometer . The RNA integrity was checked by agarose gel electrophoresis. Genomic DNA was removed by DNase treatment.Gossypium hirsutum (NCBI_GCF_000987745.1_ASM98774v1) by HISAT  [http://www.ncbi.nlm.nih.gov/sra/) (26 October 2021). The accession number is currently pending submission until acceptance of the manuscript.RNA-Seq library preparation and sequencing were performed using the standard Illumina protocols . Briefly, mRNAs were enriched from 1.5 μg total RNA by using magnetic beads with Oligo (dT) and used as templates to synthesize the first stranded cDNAs with random hexamers and produce double-stranded by using DNA Polymerase I. The products were enriched with PCR to create the final cDNA libraries after addition of A tail and ligation with sequencing adapters. Strand-specific sequencing was performed on an Illumina HiSeq X-Ten by BGI , which generated 150 bp paired-end reads. The raw reads were filtered by a series of steps, including removal of lower quality read, adapters, higher content base of N reads, to obtain clean reads. The clean reads were mapped onto reference genome of scripts) . The datp-value ≤ 0.05 [A total of six groups of cotton root sample  were used for DEGs analysis. Significantly, DEGs were identified from four comparisons, including J1-24 compared with J1-0 (J1-24/0), J1-72 compared with J1-0 (J1-72/0), L38-24 compared with L38-0 (L38-24/0) and L38-72 compared with L38-0 (L38-72/0). Fragments per kilobase per million mapped fragments (FPKM) were calculated by RSEM and used to estimate the effects of sequencing depth and gene length on the mapped read counts. Foldchange in gene expression value was calculated by FPKM J1-24/FPKM J1-0, FPKM J1-72/FPKM J1-0, FPKM L38-24/FPKM L38-0, and FPKM L38-72/FPKM L38-0. DEseq2 was used to analyze DEGs in cotton under the criteria of a corrected Foldchange ≥2 and adjusted e ≤ 0.05 . The heahttp://wego.genomics.org.cn/) (26 October 2021) in three terms, including cellular component, molecular functional and biological function, if the p-value < 0.05. Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis was then performed in KEGG Mapper (https://www.kegg.jp/kegg/mapper.html) (26 October 2021).Gene ontology (GO) term enrichment analysis of DEGs was performed using WEGO (http://www.bio-rad.com/) (26 October 2021). The relative quantification of RT-qPCR was measured by 2−ΔΔCt analysis method [18S gene (18S rRNA). Three biological replicates were performed for each experiment, with three technical replicates. The specific primers used are listed in RNA aliquots of 2.0 µg were used for cDNA synthesis by the TranScript One-Step gDNA Removal and cDNA Synthesis SuperMix kit . Quantitative PCR (qPCR) was performed using SYBR Green PCR Master Mix  on a CFX96 Touch Real-time PCR Detection System . Duncan’s multiple range test was used for three samples (p < 0.05).Student’s V. dahliae, seedlings of both L38 and VW susceptible J1 cultivars at four weeks were inoculated with Vd991. L38 plants showed highly resistant phenotype to Vd991 compared to J1 at 14 days post-inoculation , and more than 60% of clean reads were uniquely mapped to the genome of G. hirsutum in each sample file to ensure the credibility of the RNA-seq data , J1-72h compared with J1-0h (J1-72/0), L38-24 compared with L38-0h (L38-24/0), and L38-72h compared with L38-0h (L38-72/0) respectively. Thousands of DEGs were detected in the J1-24/0, J1-72/0, L38-24/0, and L38-72/0 groups. Venn diagrams of DEGs illustrate both commonly expressed and specifically expressed genes between the J1 and L38 cultivars. For up-regulated DEGs, 490 were specifically expressed in J1-24/0, 1097 were specifically expressed in J1-72/0, while 85 genes had sustained elevated levels both in J1-24/0 and J1-72/0 timepoints. Similarly, 578 genes were specifically expressed in L38-24/0, 2556 were specifically expressed in L38-72/0 group, while 771 genes had sustained expression levels in both L38-24/0 and L38-72/0 treatment groups following the V. dahliae inoculation  were identified as culation B. For doculation C. Furtheculation D.To reveal potential functions of differentially expressed genes (DEGs), we identified the Gene Ontology (GO) terms of these genes. Therefore, the DEGs were divided into six groups for further analysis, including those specifically expressed in J1-24/0 (J1-Early), specifically expressed in J1-72/0 (J1-Late), expressed both in J1-24/0, J1-72/0 (J1-Sustained), expressed only in L38-24/0 (L38-Early), expressed only in L38-72/0 (L38-Late), and expressed both in L38-24/0 and L38-72/0 (L38-Sustained). Thus, 701, 899, 1422, 3524, 390, and 2078 DEGs matching to the above-mentioned groups were assigned GO terms. The regulation of macromolecule metabolic process and regulation of RNA metabolic process were highly enriched both in cultivar J1 and L38 A. Each gIn addition, KEGG enriched pathways from each group were analyzed, and more than 100 pathways were assigned in each group, including metabolic pathways, biosynthesis of secondary metabolites and so on . SeveralAmong these GO terms and KEGG pathways, several DEGs were classified in resistance function. Therefore, the typical resistance pathway was further identified, including plant-pathogen interaction, plant hormone signal transduction, MAPK signaling pathway.CDPK), flagellin-sensing 2 (FLS2), WRKY transcription factor, avrPphB-susceptible 1 (PBS1), heat shock protein 90 (HSP90), and so on , but only DEGs of L38 assigned in MAPK/ERK kinase kinase (MEKK1) and MAP kinase (MPK4)  and PBS1  A. In effand PBS1 A. Particand PBS1 . Moreove dahliae B.TIR1; in ethylene signal transduction, DEGs only expressed in L38 were assigned in ETR; in jasmonic acid signal transduction, DEGs uniquely expressed in L38 related to JAZ; in salicylic acid signal transduction, DEGs uniquely expressed in L38 regulated non-expression of pathogenesis-related gene 1 (NPR1) and pathogenesis-related gene 1 (PR1)  A. To fur dahliae B.Suppressor of mkk1 mkk2 2 (SUMM2), that is involved in reducing cell death defense response, was the only enriched DEG of J1 in the early stage which was different from other pathways , and PR1 were the only enriched DEGs of L38  genes have been shown to play an essential role in recognizing effectors from pathogens and in triggering downstream signaling during plant disease resistance [R genes, including nucleotide-binding sites (NBSs), leucine-rich repeat (LRR), Toll/Interleukin-1 receptor (TIR), coiled-coil (CC) and transmembrane (TM) [V. dahliae inoculation. A total of 486 RGAs were identified from six groups, including J1-early, J1-late, J1-sustained, L38-early, L38-late, and L38-sustained. 358 RGAs were identified in L38, significantly higher than in J1 which displayed only 128 such RGAs (LOC107902722 (NBS-LRR), which was down regulated in J1 while up regulated in L38  . Therefouch RGAs A. Moreovuch RGAs A. A totauch RGAs B. Intered in L38 B. For thd in L38 B. In addd in L38 C. RGAs od in L38 C. Howeved in L38 C. Furthed in L38 D. Thus, V. dahliae is becoming clearer, thus assisting in the breeding of resistant cotton cultivars. In fact, the gene regulation network underlying the molecular mechanisms leading to resistance seen in several cotton cultivars with excellent VW tolerance is relatively unexplored. For instance, the cultivar Liaomian bred from the Research of Economic Crops in Liaoning Province showed higher resistance during production, but the exact mechanism underlying its resistant function remained unclear. In this study, we first confirmed the resistance phenotype of L38 compared with VW susceptible cotton J1 . These results show that the expression pattern of genes in L38 and J1 respond differentially to V. dahliae infection , RPM1 interacting 4 (RIN4), avrPphB susceptible 1 (PBS1), and Resistance to Pseudomonas syringae 5 (RPS5) [FLS2 in plant-pathogen interaction pathway, but DEGs induced in L38 were assigned to RIN4 and PBS1 related pathways  . From oupathways A. In addresponse A. These  species A. These V. dahliae inoculation. Moreover, most of RGAs in the resistant L38 cultivar were different from those in the susceptible J1 cultivar. Interestingly, 14 such RGAs that were down-regulated in J1 were up-regulated in the resistant L38 cultivar  and transmembrane leucine rich repeat (TM-LRR). More RGAs were significantly expressed in L38 than in J1 following cultivar A,B. ThisV. dahliae. Many DEGs were found through subsequent GO and KEGG analysis that related to function of VW resistance in cotton. The expression level of candidate DEGs were reconfirmed to ensure the regulation of these genes related to defense response upon V. dahliae inoculation. Moreover, the cotton RGAs were also analyzed during V. dahliae inoculation revealing that RGAs in the resistant L38 cultivar were typically different from those in the susceptible J1 cultivar, implying that the regulation network of resistance-related genes in L38 was more novel and diverse than in the susceptible cotton cultivar. This study lays a solid foundation for further in-depth analysis of myriad of candidate resistance genes in the VW resistant L38 cotton cultivar. At present we are further exploring the functional mechanism of typical resistance-related genes revealed in our study presented here to elucidate the molecular basis of VW resistance observed in the resistant L38 cotton cultivar.In short, DEGs of cotton with a putative role in VW resistance were discovered by RNA-seq analysis of two cotton cultivars differing in their resistance to In conclusion, it is our understanding that the inter-connected regulatory network of these gene clusters in the resistant cotton cultivar L38 upon pathogen infection provides a novel and comprehensive insight into the mechanism of VW resistance in pest resistant cotton cultivars. The findings of this study can be harnessed to design increased tolerance to VW in cotton, which is currently under significant threat from this devastating disease worldwide.


The stable isotopic composition of diatom silica is used as a proxy for nutrient utilisation in natural waters. This approach provides essential insight into the current and historic links between biological production, carbon cycling and climate. However, estimates of isotopic fractionation during diatom silica production from both laboratory and field studies are variable, and the biochemical pathways responsible remain unknown. Here, we investigate silicon isotopic fractionation through a series of chemical precipitation experiments that are analogous to the first stages of intracellular silica formation within the diatom silicon deposition vesicle. The novelty of our experiment is the inclusion of the R5 peptide, which is closely related to a natural biomolecule known to play a role in diatom silicification. Our results suggest that the presence of R5 induces a systematic but non-significant difference in fractionation behaviour. It thus appears that silicon isotopic fractionation in vitro is largely driven by an early kinetic fractionation during rapid precipitation that correlates with the initial amount of dissolved silica in the system. Our findings raise the question of how environmental changes might impact silicon isotopic fractionation in diatoms, and whether frustule archives record information in addition to silica consumption in surface water. Many diatom species require Si for cell growth, meaning that there is a direct link between the global silica cycle, carbon uptake and climate change4.Silicon (Si) is an important nutrient in the biology of organisms such as diatoms, sponges, radiolarians and silicoflagellates. These organisms are capable of a process known as biosilicification, in which solid silica is precipitated in a controlled manner from dissolved silicon (dSi) acquired from the environment. Marine diatoms are generally heavily silicified, and are of particular interest since they are responsible for about 40% of primary production and a significant proportion of carbon export to the seafloorn5. The process of diatom silicification is still not well-understood, but it appears to occur inside the cell through a series of tightly-controlled, coordinated and interdependent steps. Figure 6), is likely balanced by efflux processes7. This accumulated silica is then transferred to the intracellular silicon deposition vesicle (SDV) which is the site of frustule formation. The SDV is likely to be a golgi-derived vesicle with an acidic lumen8. Biomineralisation occurs within the SDV through polymerisation9. The SDV probably contains genetically-encoded, species-specific biomolecules that are thought to support and direct silica biosynthesis, and which are found intimately associated with the mature frustule. These biomolecules are represented as geometric shapes in Fig. 10, as well as the different peptides known as silaffins, silacidins and frustulins13. Other factors, such as the SDV membrane and the cytoskeleton, are also thought to be critical in forming the structure of the frustule9 but are not shown or discussed further here. The final stage of silicification involves the export of the nascent frustule to the cell exterior and subsequent maturation. While these general principles of biomineralisation are known to a certain degree, many of the specific processes underlying them remain poorly understood.Diatoms are encased in an outer cell wall, or frustule, made of hydrated amorphous silica . To date we have successfully used both Si isotopic fractionation models to study the role of organisms such as diatoms, sponges and choanoflagellates37 in the global Si cycle.The true isotopic fractionation factor of diatom silica 27, more recent studies have reported a range of fractionation factors across different diatom species38. The composition of other biosilicas, for example from sponges, is also markedly different from that of the diatoms, despite the mineral being chemically equivalent37. The same species of diatom can also display different degrees of fractionation depending upon the ambient conditions39. Finally, theoretical predictions of Si isotopic fractionation together with isotopic equilibrium experiments have shown extreme Si fractionation can occur during organosilicon complexation41. The interplay between environmental conditions and biochemical pathways that control fractionation is thus of keen interest for the basic understanding of diatom biology and for the robust interpretation of sedimentary geochemical archives of past ocean change.Several lines of evidence now point to both genetic and environmental control of isotope fractionation. Although early work reported consistent fractionation factors of 25. We find that the presence of R5 does induce a systematic but non-significant difference in fractionation behaviour. Our results suggest instead that the isotopic composition of silica is largely driven by an early kinetic fractionation during rapid precipitation that evolves towards an equilibrium state. These findings imply that the SDV could be a site of Si isotopic fractionation within the diatom cell, and that this fractionation may not be substantially affected by co-precipitation with organic macromolecules.A reasonable starting point is the assumption that fractionation might be occurring at the point of silica precipitation in the SDV, since this involves intimate engagement of the forming mineral with a complex assortment of biomacromolecules. The SDV has evaded detailed characterisation for decades, so we chose instead to study Si isotopic fractionation using the R5 model for silica precipitation in vitro. We investigated here whether the presence of R5 during Si precipitation was able to influence the Si isotopic composition of the resulting silica due to its role in the mediation of siloxane bonds42. The precipitated silica was isolated at various timepoints by low-speed centrifugation, stopping the reaction and generating two fractions: a silica pellet, and a supernatant containing buffer salts and the remaining soluble Si. Measurement of soluble Si by molybdate assay was performed after each sub-sampling event and at the end of the experiments both fractions were sub-sampled for Si isotopic analysis.Silica precipitation was induced by diluting sodium silicate from commercial stock solution into a well-defined saline buffer known as ND96 at room temperature see “”. We choIn a first set of experiments, the precipitation reaction was incubated for 8 days before the pellet and supernatant fractions were obtained and analysed. We assume that this is sufficient time for the reaction to have reached chemical equilibrium based on preliminary testing . The two higher starting concentrations resulted in a In the equilibrium experiments, the silica precipitate generally had a negative entclass1pt{minimaentclass1pt{minima46, and that at high pH , indicating that in most cases we had successfully stopped precipitation before reaching a chemical equilibrium. The pH of the supernatant was between 7.4 and 7.9. The Si isotopic fractionation in these samples followed the same trend as for equilibrium samples, with preferential precipitation of the light Si isotopes. In comparison with the equilibrium experiment, here the –10.3 mM,ion Fig. . At 3.7 47. The equilibrium experiment shows a negative correlation between pH and Figure 48  and that Si concentration alone could be the dominant factor in Si isotopic fractionation within the diatom cell. It is important to note in this regard that R5 is only a simple mimic of a more complex biomolecule (silaffin-1A1). This natural silaffin contains extensive and unusual posttranslational modifications that are absent in R512. Future work should explore whether natural silaffins can promote fractionation in a way that is not apparent with R5. The length of time required for the initial fractionation to revert to The presence of various macromolecules, such as charged peptides like R5, could potentially influence Si isotope fractionation on biologically-relevant timescales. This is reinforced by the observation that the addition of R5 can increase the rate and yield of silica precipitation50. These results imply that at least some of the variation found in these cellular studies comes from changes to Si concentration within the SDV. It is assumed that environmental conditions will influence the uptake and distribution of Si within the diatom cell7, and so this could lead to variability in Si concentration at the site of precipitation. It seems plausible that higher concentrations of dSi should give rise to greater fractionation within the frustule, and vice versa. A recent study6 suggested that dSi starvation can result in an increase in silicon content within the cell. This starvation response could potentially impact the isotopic composition of the resulting silica, by accentuating the kinetic fractionation effect. It would thus be of interest to examine the effect of dSi starvation on diatom isotopic fractionation, but to our knowledge such experiments have not yet been conducted.Intriguingly, the range of the kinetic In summary, our study confirms that Si isotopic fractionation in chemical experiments resembles that found in diatom silica from laboratory cultures and in the field. We also show that Si isotopic fractionation in the presence and absence of the R5 peptide is virtually indistinguishable. Our data confirm instead that the initial dSi concentration plays a major role in fractionation, with higher concentrations associated with increased 43. The resulting concentrations being . For all experiments and dilution factors, instantaneous precipitation was observed. pH was measured for the equilibrium (8 days) and kinetic (1 h) experiments only after the separation of the precipitate and the supernatant, and was not measured thereafter  was carried before subsampling (at the surface of the supernatant) for dSi analysis to ensure no contamination from precipitate residue. dSi concentrations were measured using the silicomolybdate method53, using a Agilent Cary 60 UV-Vis spectrophotometer for 8 days, 1h and using a nanodrop ND 1000 for the abiotic experime nt, all at the wavelength of 410 nm. For the biomimetic (R5) experiment the dSi data have been extrapolated from the Multi Collector Induced Coupled Plasma Mass-Spectrometer (MC-ICP-MS) because R5 reacted with the colorimetric molybdate reagent. At the end of all experiment , the supernatants and precipitates were separated by centrifugation. Precipitates were dissolved in 0.4N NaOH (Ananlar) at 100 dSi analyses of the supernatant were carried out after each time step. Centrifugation (300054. The 56. For all samples and standards, the three isotopes (x corresponding to All samples were purified by cation exchange chromatography using Bio-Rad AG 50W entclass1pt{minimaSupplementary Information.


Connecticut (CT) Veterans Directed Home and Community Based Services Program (VDC) is an innovative Veterans Administration (VA) services option providing veterans at risk of institutionalization with person-centered consumer-directed long-term services and supports at home. Funded by an Administration for Community Living grant, the CT Department of Aging and Disability Services partnered with the VA, the five CT Area Agencies on Aging, and UConn Health Center on Aging (UConn). UConn researchers conducted the Consumer Assessment of Healthcare Providers and Systems in Home and Community Based Services (HCBS CAHPS) survey with VDC participants (n=36) from October 2019 through March 2020. The standardized, validated HCBS CAHPS survey, which Connecticut administers to individuals in most CT Medicaid HCBS programs, is a universal, cross-disability tool to assess/improve the quality of HCBS programs. Analyses compared VDC participants’ program experiences to survey results from individuals in the Connecticut Home Care Program (CHCP) (for older adults) (n=629), Personal Care Assistance (PCA) (n=282), and Acquired Brain Injury (ABI) (n=327) waiver programs. Notably, more VDC participants (91%) knew who their support broker was, compared to CHCP, ABI, and PCA  who knew their case manager; 91% of VDC participants gave their support broker the highest rating, compared to 66% to 74% of participants in other programs who rated their case manager. This study provides strong evidence that the CT VDC program is positively impacting veterans and that the AAAs and support brokers are effectively helping them receive the HCBS they need in a consumer-directed way.


The spread of COVID-19 and large-scale travel restrictions has caused serious damage to the global tourism industry. Tourists pay additional attention to public health services and their health during travel, but studies on tourism public health service quality (TPHSQ) are limited. Therefore, this study aims to define TPHSQ and revise and validate its scale. The result of exploratory factor analysis (EFA) indicates that TPHSQ includes two dimensions “overall environmental image” and “public health facilities and management.” And based on 456 valid samples, the relationship among TPHSQ, tourists’ trust, satisfaction, and loyalty was validated using the multiple linear regression models. Results revealed the importance of the TPHSQ in improving tourists’ satisfaction and recovering their trust and loyalty. These results provided several implications for research, practice, and society that can benefit diverse stakeholders, which could accelerate the recovery of the tourism industry. At the beginning of 2020, the COVID-19 epidemic has spread globally in just a matter of weeks. This unprecedented public health crisis, which is called a black swan event, has caused an adverse impact not only on public health but also on the tourism industry. According to the data released by the World Tourism Organization, the global tourism industry will lose $1.3trillion in revenue by 2020. In addition, the total number of global tourist arrivals will drop by 1billion, or 74%, compared with the previous year, making 2020 “the worst year in tourism history” . More anFrom the practical perspective, effective public health services and guidelines in the post-epidemic era play an important role in the recovery of the tourism industry. For example, in the United States, the NY State Park required visitors to practice social distancing by keeping at least six-feet distance from each other . MoreoveHowever, most scholars only explored the importance of tourist destinations’ cleanliness and environment. Research related to tourism public health service quality (TPHSQ) and its impact on tourist loyalty (TL) is limited. For example, Previous studies covered the aspects of the TPHSQ. Specifically, with regard to sanitation and hygiene factors, In addition, although very few scholars studied this field, measuring TPHSQ is not very difficult because several proposals have been made on the multidimensional structure of service quality, such as the SERVQUAL scale , SERVICETrust originated in psychology in the 1950s. Satisfaction and loyalty are not uncommon in tourism studies. In the 1970s, as the concept of “marketing” became more pervasive in the tourism industry, Evidently, many scholars have verified the relationship between service quality and consumer loyalty, satisfaction, and trust from different areas, such as the in-flight services , mobile H1: TPHSQ has a positive and significant influence on tourist loyalty.H2: TPHSQ has a positive and significant influence on tourist satisfaction.H3: TPHSQ has a positive and significant influence on tourist trust.Considerable academic debate about the relationship between trust and satisfaction exists. Although some studies  showed tLoyalty is one of the tourist intention behaviors. Many scholars verified that tourist trust can predict tourist intention behaviors . TherefoH4: Tourist trust has a positive and significant influence on tourist satisfaction.H5: Tourist trust has a positive and significant influence on tourist loyalty.Some pieces of empirical evidence support the relationship between satisfaction and loyalty in the tourism context . In addiH6: Tourist satisfaction has a positive and significant influence on tourist loyalty.Previous studies found that tourists with higher satisfaction also have higher loyalty . As mentH7: Tourist satisfaction mediates the relationship between TPHSQ and tourist loyalty.H8: Tourist trust mediates the relationship between TPHSQ and tourist loyalty.The questionnaire survey of this empirical study is divided into five parts. The first part mainly includes the demographic and personal background information of the participants. The second part is about the TPHSQ, mainly including the cleanliness of the environment and the public toilet, and whether to establish infirmaries and the public health service system in the scenic area. Then, the third part is used to measure the tourist trust, and the fourth and fifth parts are, respectively used to evaluate tourist satisfaction and loyalty after travel. Notably, we have set up two questions at the end of the first part of the questionnaire. One of which is “Which tourist attraction you have been to most recently?”, which could help tourists recall their most recent travel experience. Moreover, if they skip this question and do not answer, then the questionnaire will be considered invalid. The other question is a simple mathematical question, which is also used to test the validity of the data. All items were assessed using a five-point Likert-type scale ranging from extremely disagree (1) to extremely agree (5).Based on the literature review, the measurement items for the study variables were adopted . In partPrevious research shaped other extended study variables,  were male, and 65.4% (n=298) were female. Most of them were between 19 and 24years old, or 44.7% and those under 56years old accounted for 97.8%. In addition, more than half of the respondents, 62.9% (n=287), held an undergraduate degree. In this study, a convenience sampling method was used to distribute questionnaires through online social media platforms from December 17 to December 29, 2020. The link for participants to fill out online is N=456) is divided into S1=150 and S2=306. The former is used for EFA and the reliability test, whereas the latter uses AMOS 22.0 software for confirmatory factor analysis (CFA) and hypothesis testing. Furthermore, to test the influence of multiple intermediaries on loyalty, this study used Hayes’s Model 6 and Bootstrap methods to conduct a series of intermediary analyses, verifying the intermediary role of tourist trust and satisfaction.At the beginning of this study, SPSS 22.0 was used to analyze the data and perform descriptive statistics on the demographic characteristics of the respondents. Next, the total sample . The CR values for all the constructs ranged from 0.806 to 0.884, which exceeded the threshold value of 0.70 , and TPHSQ significantly and positively affected tourist trust  and satisfaction  as shown in This study predicted that improving the TPHSQ would increase tourist loyalty (H1), trust (H2), and satisfaction (H3). The results showed that TPHSQ had a significant positive effect on loyalty . The results supported H4.This study verified the relationship between tourists’ trust in public health services and their satisfaction. The results showed that a significant positive effect exists between tourists’ trust in public health services and their satisfaction  and a significant positive correlation is found between tourist experience satisfaction and loyalty . These results support H5 and H6.Hypotheses 5 and 6 indicated that tourist trust and satisfaction significantly influence loyalty. The results showed that a significant positive correlation exists between tourist trust and loyalty ]. The indirect effect of TPHSQ on loyalty was verified through the significant mediation of tourist trust  and satisfaction . Thus, this result indicates that tourist trust and satisfaction play a partially mediating role in the effect of TPHSQ on their loyalty, thereby verifying H7 and H8.The results showed that the indirect effect of TPHSQ on loyalty was significant under the influence of chain mediators  needs to be further explored and verified to have a significant effect.The model in this study is a multi-mediator, which involves the relationship between two mediating variables, and these multiple mediating variables showed sequential characteristics and formed a chain of mediators. Therefore, the chain of mediators of tourist trust and satisfaction [First, a significant positive impact is observed from the relationship between TPHSQ and loyalty and the results, which is consistent with the research results of . In otheThen, this study not only verified the mechanism of the effect of TPHSQ on loyalty but also concluded that TPHSQ consists of two dimensions, namely, overall environmental image and public health facilities and management. This finding is consistent with the established findings of . SpecifiFirst, the TPHSQ affects tourist trust because public health services are different from other services in that they involve human health and safety, as evidenced by Maslow’s hierarchy of needs theory. In this theory, safety needs are the most sensitive needs of the human, in addition to physiological needs. Therefore, a satisfactory tourism public health service will allow tourists to conduct other experiences without fear . Second,Furthermore, the current study confirmed a significant positive effect of tourist trust on satisfaction, which is consistent with the findings of Tourism public health services are closely related to the health and experience of every tourist. In the post-epidemic era, if tourism companies can ensure that every tourist can receive high-quality public health services during travel, and then this can help regain travelers’ confidence and increase their loyalty and the recovery of tourism industry. This study aims to define and measure the TPHSQ and explore its impact on loyalty. The results showed that the TPHSQ consists of two dimensions, namely, overall environmental image and public health facilities and management. And it is positively correlated with tourist loyalty, and trust and satisfaction play an intermediary role in the TPHSQ–loyalty relationship. In addition, comprehensively, a single intermediary path based on satisfaction is better than a multi-chain intermediary path based on trust–satisfaction. The empirical results supported the theoretical model and hypothesis.Some scholars predicted that the panic caused by the COVID-19 outbreak may have a long-term impact on the tourism industry . TouristFirst, tourist destinations must change their attitude toward the overall environment and cleanliness. The cleanliness of the tourist environment is not the core of every travel and tourists are often attracted by other more beautiful landscapes or impressive services. However, as long as the tourists perceive the environment and sanitation below expectations, satisfaction will be greatly affected, especially during a public health crisis . TherefoSecond, tourist destinations must standardize public health facilities and management. Taking public toilets in scenic spots in China as an example, despite the implementation of the Toilet Revolution policy, unreasonable numbers, low convenience, and poor facilities in the public toilets still exist. In addition, even some of the toilets show a “different” situation, where the exterior decoration is neat and tidy, into the toilet but very poor hygiene . These cThis study provides valuable management insights for the sustainable development of tourist destinations in the post-epidemic era. However, several limitations exist. One of them is that the current study collected data from Chinese tourists, so the research results may not be applicable to tourist destinations in other countries. Thus, future research can explore cross-cultural aspects for international or cross-cultural tourists. In addition, common problems related to the measurement errors of dependent and independent variables (IVs) exist in linear models. Finally, as the study validated a limited number of variables, future scholars can explore the relationship between the quality of tourism public health services and more other variables, such as tourists’ emotions and perceived risks.amber939999@163.com.The datasets presented in this article are not readily available but the raw data supporting the conclusions of this manuscript will be made available by the authors to any qualified researcher. Requests to access the datasets should be directed to Jiayu Han JH and YZ contributed to the conception of the study. JH collected and organized the data. JH and YZ contributed significantly to analysis and manuscript preparation. YZ and SC performed the data analyses and wrote the manuscript. RL and MZ helped perform the analysis with constructive discussions. MZ is responsible for the overall project. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.