Association between psychological distress trajectories from adolescence to midlife and mental health during the pandemic: evidence from two British birth cohorts.

BACKGROUND: This paper examined whether distinct life-course trajectories of psychological distress from adolescence to midlife were associated with poorer mental health outcomes during the pandemic. METHODS: We present a secondary analysis of two nationally representative British birth cohorts, the 1958 National Child Development Study (NCDS) and 1970 British Cohort Study (BCS70). We used latent variable mixture models to identify pre-pandemic longitudinal trajectories of psychological distress and a modified Poisson model with robust standard errors to estimate associations with psychological distress, life satisfaction and loneliness at different points during the pandemic. RESULTS: Our analysis identified five distinct pre-pandemic trajectories of psychological distress in both cohorts. All trajectories with prior symptoms of psychological distress irrespective of age of onset, severity and chronicity were associated with a greater relative risk of poorer mental health outcomes during the pandemic and the probability of poorer mental health associated with psychological distress trajectories remained fairly constant. The relationship was not fully attenuated when most recent pre-pandemic psychological distress and other midlife factors were controlled for. CONCLUSIONS: Whilst life-course trajectories with any prior symptoms of psychological distress put individuals at greater risk of poor mental health outcomes during the pandemic, those with chronic and more recent occurrences were at highest risk. In addition, prior poor mental health during the adult life-course may mean individuals are less resilient to shocks, such as pandemics. Our findings show the importance of considering heterogeneous mental health trajectories across the life-course in the general population in addition to population average trends.

Developing and testing a case-management intervention to support the return to work of health care workers with common mental health disorders.

BACKGROUND: To assess the feasibility and acceptability of conducting a trial of the clinical effectiveness and cost-effectiveness of a new case-management intervention to facilitate the return to work of health care workers, on sick leave, having a common mental disorder (CMD). METHODS: A mixed methods feasibility study. RESULTS: Systematic review examined 40 articles and 2 guidelines. Forty-nine National Health Service Occupational Health (OH) providers completed a usual care survey. We trained six OH nurses as case managers and established six recruitment sites. Forty-two out of 1938 staff on sick leave with a CMD were screened for eligibility, and 24 participants were recruited. Out of them, 94% were female. Eleven participants received the intervention and 13 received usual care. Engagement with most intervention components was excellent. Return-to-work self-efficacy improved more in the intervention group than in the usual care group. Qualitative feedback showed the intervention was acceptable. CONCLUSIONS: The intervention was acceptable, feasible and low cost to deliver, but it was not considered feasible to recommend a large-scale effectiveness trial unless an effective method could be devised to improve the early OH referral of staff sick with CMD. Alternatively, the intervention could be trialled as a new stand-alone OH intervention initiated at the time of usual OH referral.

Do initiation rites hasten sexual debut among adolescent girls? A longitudinal analysis from Ghana.

Many Ghanaians identify their country's most enduring female initiation rite as a risk factor for early sexual debut, claiming that initiates interpret the rite as a normative starting point for sexual activity as was standard in the past. However, the assumption that African initiation rites may hasten sexual debut has not been statistically substantiated. This study explores this association using three waves of longitudinal data collected between 2010 to 2013 from 690 girls and young women aged 12-19, about half of whom had participated in the rite. The results suggest that initiates typically participate in the rite at age 11 and begin having sex around age 16, about six months earlier than non-initiates. Results from survival analyses correspondingly indicate that initiates are 50% more likely to report sexual debut than their non-initiated counterparts. This relationship remains robust when accounting for confounding variables and reverse causality and is not moderated by socioeconomic status. Findings suggest that initiation rites should be understood as having potentially meaningful implications for adolescent sexual debut and sexual and reproductive health outcomes in sub-Saharan Africa. Capitalising on initiation rites for their role in sexual socialisation may be a valuable opportunity to promote sexual and reproductive health among youth.

The metabolic upper critical temperature of the human thermoneutral zone.

INTRODUCTION: The thermoneutral zone (TNZ) defines the range of ambient temperatures at which resting metabolic rate is at a minimum without sensible dry heat loss; the body not needing to defend its core temperature. The TNZ has been defined in a number of species yet surprisingly, in humans only its lower limit has been well characterised; indeed, it is not yet clear if there is an upper limit at which metabolic rate increases. AIM: To evaluate the evidence for a metabolic upper critical temperature to the thermoneutral zone in humans. METHODS: We synthesised current evidence about an upper limit to the human TNZ, highlighting the contradictions in the literature, and then discussed likely explanations for those contradictions. RESULTS: The data from relevant studies differ in terms of whether they indicate that the TNZ has an upper limit, and this was related to the fundamental type of heat exposure protocol employed. Those studies showing evidence for an upper limit associated that limit with a wide range of temperatures. CONCLUSIONS: We offer suggestions for future studies that should clarify the presence/absence of an upper limit to the TNZ and if present, where it lies.

Prediction and monitoring of relapse in stage III melanoma using circulating tumor DNA.

BACKGROUND: The advent of effective adjuvant therapies for patients with resected melanoma has highlighted the need to stratify patients based on risk of relapse given the cost and toxicities associated with treatment. Here we assessed circulating tumor DNA (ctDNA) to predict and monitor relapse in resected stage III melanoma. PATIENTS AND METHODS: Somatic mutations were identified in 99/133 (74%) patients through tumor tissue sequencing. Personalized droplet digital PCR (ddPCR) assays were used to detect known mutations in 315 prospectively collected plasma samples from mutation-positive patients. External validation was performed in a prospective independent cohort (n = 29). RESULTS: ctDNA was detected in 37 of 99 (37%) individuals. In 81 patients who did not receive adjuvant therapy, 90% of patients with ctDNA detected at baseline and 100% of patients with ctDNA detected at the postoperative timepoint relapsed at a median follow up of 20 months. ctDNA detection predicted patients at high risk of relapse at baseline [relapse-free survival (RFS) hazard ratio (HR) 2.9; 95% confidence interval (CI) 1.5-5.6; P = 0.002] and postoperatively (HR 10; 95% CI 4.3-24; P < 0.001). ctDNA detection at baseline [HR 2.9; 95% CI 1.3-5.7; P = 0.003 and postoperatively (HR 11; 95% CI 4.3-27; P < 0.001] was also associated with inferior distant metastasis-free survival (DMFS). These findings were validated in the independent cohort. ctDNA detection remained an independent predictor of RFS and DMFS in multivariate analyses after adjustment for disease stage and BRAF mutation status. CONCLUSION: Baseline and postoperative ctDNA detection in two independent prospective cohorts identified stage III melanoma patients at highest risk of relapse and has potential to inform adjuvant therapy decisions.

Rapid local acceleration of relativistic radiation-belt electrons by magnetospheric chorus.

Recent analysis of satellite data obtained during the 9 October 2012 geomagnetic storm identified the development of peaks in electron phase space density, which are compelling evidence for local electron acceleration in the heart of the outer radiation belt, but are inconsistent with acceleration by inward radial diffusive transport. However, the precise physical mechanism responsible for the acceleration on 9 October was not identified. Previous modelling has indicated that a magnetospheric electromagnetic emission known as chorus could be a potential candidate for local electron acceleration, but a definitive resolution of the importance of chorus for radiation-belt acceleration was not possible because of limitations in the energy range and resolution of previous electron observations and the lack of a dynamic global wave model. Here we report high-resolution electron observations obtained during the 9 October storm and demonstrate, using a two-dimensional simulation performed with a recently developed time-varying data-driven model, that chorus scattering explains the temporal evolution of both the energy and angular distribution of the observed relativistic electron flux increase. Our detailed modelling demonstrates the remarkable efficiency of wave acceleration in the Earth's outer radiation belt, and the results presented have potential application to Jupiter, Saturn and other magnetized astrophysical objects.

Surveillance imaging with FDG-PET/CT in the post-operative follow-up of stage 3 melanoma.

Background: As early detection of recurrent melanoma maximizes treatment options, patients usually undergo post-operative imaging surveillance, increasingly with FDG-PET/CT (PET). To assess this, we evaluated stage 3 melanoma patients who underwent prospectively applied and sub-stage-specific schedules of PET surveillance. Patients and methods: From 2009, patients with stage 3 melanoma routinely underwent PET +/- MRI brain scans via defined schedules based on sub-stage-specific relapse probabilities. Data were collected regarding patient characteristics and outcomes. Contingency analyses were carried out of imaging outcomes. Results: One hundred and seventy patients (stage 3A: 34; 3B: 93; 3C: 43) underwent radiological surveillance. Relapses were identified in 65 (38%) patients, of which 45 (69%) were asymptomatic. False-positive imaging findings occurred in 7%, and 6% had treatable second (non-melanoma) malignancies. Positive predictive values (PPV) of individual scans were 56%-83%. Negative scans had predictive values of 89%-96% for true non-recurrence [negative predictive values (NPV)] until the next scan. A negative PET at 18 months had NPVs of 80%-84% for true non-recurrence at any time in the 47-month (median) follow-up period. Sensitivity and specificity of the overall approach of sub-stage-specific PET surveillance were 70% and 87%, respectively. Of relapsed patients, 33 (52%) underwent potentially curative resection and 10 (16%) remained disease-free after 24 months (median). Conclusions: Application of sub-stage-specific PET in stage 3 melanoma enables asymptomatic detection of most recurrences, has high NPVs that may provide patient reassurance, and is associated with a high rate of detection of resectable and potentially curable disease at relapse.

Neighbourhoods and obesity: A prospective study of characteristics of the built environment and their association with adiposity outcomes in children in Montreal, Canada.

This paper examined prospective associations between built environment features assessed at baseline using direct audits and adiposity outcomes two years later in Montreal, Canada. Data stem from the Quebec Adipose and Lifestyle Investigation in Youth study of 630 children aged 8-10 years with a parental history of obesity. Baseline measurements took place between 2005 and 2008. Follow-up took place between 2008 and 2011. Built environment features were assessed at baseline in up to 10 contiguous street segments around participants' residential addresses using on-site audits. Analyses were restricted to participants who reported the same address both at baseline and follow-up. Prospective associations between adiposity outcomes at follow-up (BMI z-score and waist-height ratio) and built environment features at baseline (traffic-calming features, pedestrian aids, disorder, physical activity facilities, convenience stores, and fast-food restaurants) were examined using multivariable regression models. 391 children were included in the analyses. In fully-adjusted models, children living in residential areas with presence of pedestrian aids had lower BMI z-score, and lower waist-height ratio. Also, children residing in residential areas with at least one convenience store had lower BMI z-score, and lower waist-height ratio at follow-up. Findings provide evidence of the potential role of street-level urban design features in shaping childhood adiposity. To better inform policy and intervention, future research should explore the possibility of reducing obesogenic neighbourhoods by enhancing street-level design features.

Fast Diffusion of Ultrarelativistic Electrons in the Outer Radiation Belt: 17 March 2015 Storm Event.

Inward radial diffusion driven by ULF waves has long been known to be capable of accelerating radiation belt electrons to very high energies within the heart of the belts, but more recent work has shown that radial diffusion values can be highly event-specific, and mean values or empirical models may not capture the full significance of radial diffusion to acceleration events. Here we present an event of fast inward radial diffusion, occurring during a period following the geomagnetic storm of 17 March 2015. Ultrarelativistic electrons up to ∼8 MeV are accelerated in the absence of intense higher-frequency plasma waves, indicating an acceleration event in the core of the outer belt driven primarily or entirely by ULF wave-driven diffusion. We examine this fast diffusion rate along with derived radial diffusion coefficients using particle and fields instruments on the Van Allen Probes spacecraft mission.

Association between metabolic syndrome and gingival inflammation in obese children.

BACKGROUND AND OBJECTIVE: Our previous work showed a positive association between metabolic syndrome (MetS) and gingival crevicular fluid (GCF) tumour necrosis factor-alpha (TNF-α) in a sample of obese and non-obese children. However, whether this association persists among obese children is unknown. We aim to investigate the extent to which MetS is associated with GCF TNF-α level among obese children. METHODOLOGY: We performed a cross-sectional analysis using data from visit 1 of the QUebec Adipose and Lifestyle InvesTigation in Youth cohort. A total of 219 obese children aged 8-10 years, for whom data were available for both MetS and TNF-α, were included in our analysis. The independent variable, MetS, was defined according to the International Diabetes Federation recommendations. GCF samples were collected from the gingival sulcus using a paper strip, and the concentration of TNF-α was determined by enzyme-linked immunosorbent assay. Analyses included descriptive statistics and sex-specific linear regression analyses adjusting for potential confounders. RESULTS: In this sample comprising only obese children, 24 (10.9%) had MetS. Among obese boys, those with MetS had 44.9% higher GCF TNF-α (95% confidence interval: 16.5%-73.3%) compared to those without MetS. No such association was detected in obese girls. CONCLUSION: MetS was positively associated with GCF TNF-α concentration in obese boys. These results suggest that obese boys with MetS may have a worse gingival health profile compared to their obese counterpart without MetS.

Considering Tangible Benefit for Interdependent Donors: Extending a Risk-Benefit Framework in Donor Selection.

From its infancy, live donor transplantation has operated within a framework of acceptable risk to donors. Such a framework presumes that risks of living donation are experienced by the donor while all benefits are realized by the recipient, creating an inequitable distribution that demands minimization of donor risk. We suggest that this risk-tolerance framework ignores tangible benefits to the donor. A previously proposed framework more fully considers potential benefits to the donor and argues that risks and benefits must be balanced. We expand on this approach, and posit that donors sharing a household with and/or caring for a potential transplant patient may realize tangible benefits that are absent in a more distantly related donation (e.g. cousin, nondirected). We term these donors, whose well-being is closely tied to their recipient, "interdependent donors." A flexible risk-benefit model that combines risk assessment with benefits to interdependent donors will contribute to donor evaluation and selection that more accurately reflects what is at stake for donors. In so doing, a risk-benefit framework may allow some donors to accept greater risk in donation decisions.

The National Landscape of Living Kidney Donor Follow-Up in the United States.

In 2013, the Organ Procurement and Transplantation Network (OPTN)/ United Network for Organ Sharing (UNOS) mandated that transplant centers collect data on living kidney donors (LKDs) at 6 months, 1 year, and 2 years postdonation, with policy-defined thresholds for the proportion of complete living donor follow-up (LDF) data submitted in a timely manner (60 days before or after the expected visit date). While mandated, it was unclear how centers across the country would perform in meeting thresholds, given potential donor and center-level challenges of LDF. To better understand the impact of this policy, we studied Scientific Registry of Transplant Recipients data for 31,615 LKDs between January 2010 and June 2015, comparing proportions of complete and timely LDF form submissions before and after policy implementation. We also used multilevel logistic regression to assess donor- and center-level characteristics associated with complete and timely LDF submissions. Complete and timely 2-year LDF increased from 33% prepolicy (January 2010 through January 2013) to 54% postpolicy (February 2013 through June 2015) (p < 0.001). In an adjusted model, the odds of 2-year LDF increased by 22% per year prepolicy (p < 0.001) and 23% per year postpolicy (p < 0.001). Despite these annual increases in LDF, only 43% (87/202) of centers met the OPTN/UNOS-required 6-month, 1-year, and 2-year LDF thresholds for LKDs who donated in 2013. These findings motivate further evaluation of LDF barriers and the optimal approaches to capturing outcomes after living donation.

Social media and organ donation: Ethically navigating the next frontier.

As the organ shortage continues to grow, the creation of social media communities by transplant hospitals and the public is rapidly expanding to increase the number of living donors. Social media communities are arranged in myriad ways and without standardization, raising concerns about transplant candidates' and potential donors' autonomy and quality of care. Social media communities magnify and modify extant ethical issues in deceased and living donation related to privacy, confidentiality, professionalism, and informed consent, and increase the potential for undue influence and coercion for potential donors and transplant candidates. Currently, no national ethical guidelines have been developed in the United States regarding the use of social media to foster organ transplantation. We provide an ethical framework to guide transplant stakeholders in using social media for public and patient communication about transplantation and living donation, and offer recommendations for transplant clinical practice and future research.

The Living Donor Collective: A Scientific Registry for Living Donors.

In the setting of an overall decline in living organ donation and new questions about long-term safety, a better understanding of outcomes after living donation has become imperative. Adequate information on outcomes important to donors may take many years to ascertain and may be evident only by comparing large numbers of donors with suitable controls. Previous studies have been unable to fully answer critical questions, primarily due to lack of appropriate controls, inadequate sample size, and/or follow-up duration that is too short to allow detection of important risks attributable to donation. The Organ Procurement and Transplantation Network does not follow donors long term and has no prospective control group with which to compare postdonation outcomes. There is a need to establish a national living donor registry and to prospectively follow donors over their lifetimes. In addition, there is a need to better understand the reasons many potential donors who volunteer to donate do not donate and whether the reasons are justified. Therefore, the US Health Resources and Services Administration asked the Scientific Registry of Transplant Recipients to establish a national registry to address these important questions. Here, we discuss the efforts, challenges, and opportunities inherent in establishing the Living Donor Collective.

School food environments associated with adiposity in Canadian children.

BACKGROUND/OBJECTIVES: Targeting obesogenic features of children's environment that are amenable to change represents a promising strategy for health promotion. The school food environment, defined as the services and policies regarding nutrition and the availability of food in the school and surrounding neighborhood, is particularly important given that students travel through the school neighborhood almost daily and that they consume a substantial proportion of their calories at school. SUBJECTS/METHODS: As part of the Quebec Adipose and Lifestyle Investigation in Youth (QUALITY) cohort study, we assessed features of school indoor dietary environment and the surrounding school neighborhoods, when children were aged 8-10 years (2005-2008). School principals reported on food practices and policies within the schools. The density of convenience stores and fast-food outlets surrounding the school was computed using a Geographical Information System. Indicators of school neighborhood deprivation were derived from census data. Adiposity outcomes were measured in a clinical setting 2 years later, when participants were aged 10-12 years (2008-2011). We conducted cluster analyses to identify school food environment types. Associations between school types and adiposity were estimated in linear regression models. RESULTS: Cluster analysis identified three school types with distinct food environments. Schools were characterized as: overall healthful (45%); a healthful food environment in the surrounding neighborhood, but an unhealthful indoor food environment (22%); or overall unhealthful (33%). Less healthful schools were located in more deprived neighborhoods and were associated with greater child adiposity. CONCLUSIONS: Despite regulatory efforts to improve school food environments, there is substantial inequity in dietary environments across schools. Ensuring healthful indoor and outdoor food environments across schools should be included in comprehensive efforts to reduce obesity-related health disparities.

Screening for latent tuberculosis in UK health care workers.

BACKGROUND: Active tuberculosis (TB) infection was diagnosed in two health care workers (HCWs) originally from high-incidence countries at a National Health Service (NHS) hospital trust in Northern England. In response, the trust screened current clinical employees from countries with a high TB prevalence for active and latent TB infection (LTBI). AIMS: To identify the number of HCWs, within the organization, who are at risk of TB infection. METHODS: Clinical employees from countries with a high TB prevalence (those described by the World Health Organization as having an incidence of >40 cases per 100000 populations) were reviewed. Employees were identified via human resource systems and occupational health records, from which nationality or country of birth was identified. A letter was sent to identified employees advising of the rationale for a reviewed screening process and inviting them to attend for an interferon-gamma release assay (IGRA) blood test. RESULTS: A total of 587 clinical staff were identified as fitting the criteria of clinical HCWs from high-incidence countries. Of 469 HCWs screened, 27% screened positive using IGRA. This represented 4% of the total clinical workforce for the organization. CONCLUSIONS: A considerable proportion of the workforce at this NHS hospital trust had previously undiagnosed LTBI, carrying a risk of conversion to active disease. Further action, such as treatment of LTBI or increased workforce awareness of symptoms of active disease, could help to reduce the risk of transmission of TB to patients and the need for associated 'look-back' exercises.

Investigating Socioeconomic Position in Dental Caries and Traumatic Dental Injury among Children in Quebec.

OBJECTIVES: Socioeconomic position (SEP) is inversely associated with most oral health outcomes, but the patterns of association may vary depending on the specific outcome. We estimated associations between SEP and two oral health outcomes, dental caries and traumatic dental injuries (TDI), in Quebec children. METHODS: We used data from the baseline visit of the QUALITY (QUebec Adipose and Lifestyle Investigation in Youth) Cohort, an ongoing study in Montreal and Quebec, Canada. The analytical sample included 590 children aged 8-10 years. Data on parents' SEP (household income, education) and children's health behaviours and involvement in sports were obtained through questionnaires and interviews. Oral health outcomes (dental caries and TDI in permanent teeth) were assessed by clinical oral exam. Negative binomial regression was used to model dental caries (DMFS index) and number of teeth with TDI adjusting for selected covariates. RESULTS: The mean (SD) DMFS and number of TDI were 0.61 (1.43) and 0.12 (0.43), respectively. Compared to the upper quartile of income, children in the lower quartile had a DMFS approximately 3 times higher (PRR=2.68, 95% CI: 1.43, 5.04). Adjusting for oral health and nutritional behaviours had no effect. Conversely, children in the highest income quartile had a 3 times higher number of teeth with TDI compared to the lowest quartile (PRR=3.14, 95% CI: 1.22, 8.08). Physical activity did not explain this relationship. Parents' education was not associated with dental caries or TDI. CONCLUSION: SEP seems to play a different role in the cause of dental caries and TDI.

Mechanical efficiency in children with different body weight: a longitudinal assessment of the quality cohort.

Net mechanical efficiency (MEnet), which reflects the body's ability to transfer energy above resting levels in external work, is similar in young children regardless of their body weights. However, it is unclear whether MEnet remains stable during growth and maturation. We sought to determine whether net mechanical efficiency (MEnet) changes over a period of 3 years in children and to identify the factors associated with possible changes. A total of 169 children participating in the QUALITY (Quebec Adipose and Lifestyle InvesTigation in Youth) cohort completed an incremental cycling test, resulting in the same maximal power output during both visits. For MEnet, resting energy consumption was subtracted from total energy consumption at each exercise stage. Physical activity was measured using an accelerometer worn for 7 days. Participants were measured at year one and again two years later. MEnet did not differ across the visits at the 25, 50 and 75 watt stages. However, the participants exhibited lower MEnet values at follow-up for the 100 and 125 W stages (23(3) vs. 20(1)%; 25(4) vs. 20(2)%; p<0.01). Declines in MEnet correlated positively with declines in moderate-to-vigorous physical activity levels (r=0.78, p<0.05). The declines in moderate-to-vigorous physical activity levels across the visits were identified as significant predictors of MEnet changes at 100 and 125 W over 3 years, accounting for 22% of the relationship. In children, MEnet, determined at high exercise intensity, decreases within a period of three years, and the decrement appeared to be related to moderate-to-vigorous physical activity.

A case series of anal melanoma including the results of treatment with imatinib in selected patients.

AIM: Anal melanoma is a rare malignancy with a poor prognosis. METHOD: All patients with a diagnosis of anal melanoma treated at a single institution between 2000 and 2012 were identified and their treatment and outcome were evaluated. RESULTS: Sixteen patients had a median survival of 2.9 years. Fourteen had Stage I or II disease with a median survival of 4.0 years and progression-free survival of 1.5 years. When used for disease staging, whole body positron emission tomography/CT identified an additional three sites of metastasis in five patients compared with CT of the chest, abdomen and pelvis. Surgery involved wide local excision or abdominoperineal excision with respective local recurrence rates of 50% and 66%. Eleven patients underwent testing for c-Kit mutations, of whom five were positive. Four of these were treated with the tyrosine kinase inhibitor imatinib, and showed rapid response of metastases outside the central nervous system. CONCLUSION: The outcome of this malignancy remains poor. PET is the modality of choice for disease staging. Testing tumours for c-Kit mutations may allow selected patients to participate in trials of tyrosine kinase inhibitors.

An in vitro evaluation of gaseous microemboli handling by contemporary venous reservoirs and oxygenator systems using EDAC.

Gaseous microemboli (GME) generated during cardiopulmonary bypass (CPB) can present a significant risk to patient outcomes, specifically if they are delivered to the cerebral vasculature. A number of GME sources have been identified, leading to improved clinical practice and equipment design to ameliorate the presence and intensity of GME during CPB. Recently, a number of new venous reservoir/oxygenator systems have entered the market, including the Sorin Inspire6 and Inspire8, the Terumo FX15 and FX25 and the Maquet Quadrox-i. The goal of the current study was to evaluate the GME-handling capacity of these contemporary venous reservoirs, oxygenators and complete systems, as well as our currently used Sorin Synthesis, using the EDAC system. The venous reservoir of the Quadrox-i was the most effective in removing all sizes of GME and total GME load, while the Synthesis was the least effective. The FX15 and FX25 were least effective removing small GME, while the FX15 and Quadrox-i were the least effective at removing medium GME. The Quadrox-i was least effective at removing large GME. In terms of complete venous reservoir/oxygenator systems, the Synthesis permitted the greatest amount of GME to pass, while the other systems appeared largely equivalent.