Accuracy of human sperm DNA oxidation quantification and threshold determination using an 8-OHdG immuno-detection assay.

STUDY QUESTION: Can a discriminant threshold be determined for human sperm DNA oxidation? SUMMARY ANSWER: A discriminant threshold was found with 65.8% of 8-hydroxy-2'-deoxyguanosine (8-OHdG)-positive sperm cells and a mean intensity of fluorescence (MIF) of 552 arbitrary units. WHAT IS KNOWN ALREADY: Oxidative stress is known to interfere with sperm quality and fertilizing capacity. However, current practice does not include the routine determination of oxidative DNA damage in spermatozoa; optimized consensus protocols are lacking and no thresholds of normality have been established. STUDY DESIGN, SIZE, DURATION: Intra- and inter-method comparisons between four protocols (I-IV) were conducted to determine the most relevant and efficient means of assessing human sperm 8-OHdG content. Tests of assay repeatability, specificity, sensitivity and stability were performed to validate an optimized methodology for routine diagnostic use. PARTICIPANTS/MATERIALS, SETTING, METHODS: This prospective study compared three immuno-detection methods including immunocytochemistry, fluorescence microscopy and flow cytometry. Sperm DNA oxidation for 80 patients was determined relative to semen parameters and clinical conditions, using the selected immuno-detection protocol in comparison with a commercial kit. These patients (age 35 ± 1 years: mean ± SEM) presented with normozoospermic (n = 40) or altered parameters (necro- or/and astheno- or/and teratozoospermia or/and leukocytospermia). MAIN RESULTS AND THE ROLE OF CHANCE: Significant positive Pearson and Spearman correlations were determined for 8-OHdG values and sperm parameters using protocol III. A notable high and positive correlation was revealed for MIF with BMI and leukocyte concentration. Protocol III was the most discriminating method regarding assay repeatability, specificity, sensitivity, stability and reliability for sperm parameter alterations, in particular leukocytospermia according to parametric or non-parametric tests, effect-size determinations and factorial analysis such as principal component analysis and factor discriminant analysis. Of interest is that 39% of the subjects with 'pathological' sperm DNA oxidation values were normozoospermic. LIMITATIONS, REASONS FOR CAUTION: The oligozoospermic population was not evaluated in this study because insufficient material was available to carry out the comparisons. However, spermatozoa concentration was taken into account in the statistical analysis. WIDER IMPLICATIONS OF THE FINDINGS: Our study is the first validation of a protocol to determine a discriminant threshold for human sperm DNA oxidation. The protocol's detection accuracy for 8-OHdG human sperm DNA residues, stability over time, and relationship to human sperm quality were demonstrated. The assay should find application in the diagnosis of male factor infertility associated with oxidative stress. STUDY FUNDING/COMPETING INTEREST(S): This work was funded by institutional grants from the CNRS, INSERM and Université Clermont Auvergne (to J.R.D.) and by Clermont-Ferrand Hospital-CECOS research funds (to L.J. and F.B.). P.G., A.M., R.J.A. and J.D. are, respectively, CEO, scientific director and scientific advisors of a US-based biotech company (Celloxess, Princeton, NJ, USA) involved in preventative medicine with a focus on the generation of antioxidant oral supplements.

Dyslipidemia alters sperm maturation and capacitation in LXR-null mice.

Lipid metabolism disorders (dyslipidemia) are causes of male infertility, but little is known about their impact on male gametes when considering post-testicular maturation events, given that studies concentrate most often on endocrine dysfunctions and testicular consequences. In this study, three-month-old wild-type (wt) and Liver-X-Receptors knock out (Lxrα;ß-/- ) males were fed four weeks with a control or a lipid-enriched diet containing 1.25% cholesterol (high cholesterol diet (HCD)). The HCD triggered a dyslipidemia leading to sperm post-testicular alterations and infertility. Sperm lipids were analyzed by LC-MS and those from Lxrα;ß-/- males fed the HCD showed higher chol/PL and PC/PE ratios compared to wt-HCD (P < 0.05) and lower oxysterol contents compared to wt (P < 0.05) or Lxrα;ß-/- (P < 0.05). These modifications impaired membrane-associated events triggering the tyrosine phosphorylation normally occurring during the capacitation process, as shown by phosphotyrosine Western blots. Using flow cytometry, we showed that a smaller subpopulation of spermatozoa from Lxrα;ß-/- -HCD males could raise their membrane fluidity during capacitation (P < 0.05 vs wt or wt-HCD) as well as their intracellular calcium concentration (P < 0.05 vs Lxrα;ß-/- and P < 0.001 vs wt). The accumulation of the major sperm calcium efflux pump (PMCA4) was decreased in Lxrα;ß-/- males fed the HCD (P < 0.05 vs Lxrα;ß-/- and P < 0.001 vs wt). This study is the first showing an impact of dyslipidemia on post-testicular sperm maturation with consequences on the capacitation signaling cascade. It may lead to the identification of fertility prognostic markers in this pathophysiological situation, which could help clinicians to better understand male infertilities which are thus far classified as idiopathic.

Mammalian sperm nuclear organization: resiliencies and vulnerabilities.

Sperm cells are remarkably complex and highly specialized compared to somatic cells. Their function is to deliver to the oocyte the paternal genomic blueprint along with a pool of proteins and RNAs so a new generation can begin. Reproductive success, including optimal embryonic development and healthy offspring, greatly depends on the integrity of the sperm chromatin structure. It is now well documented that DNA damage in sperm is linked to reproductive failures both in natural and assisted conception (Assisted Reproductive Technologies [ART]). This manuscript reviews recent important findings concerning - the unusual organization of mammalian sperm chromatin and its impact on reproductive success when modified. This review is focused on sperm chromatin damage and their impact on embryonic development and transgenerational inheritance.

Les spermatozoïdes sont des cellules particulièrement complexes et très spécialisées comparées aux cellules somatiques. Leur rôle est de délivrer dans l'ovule le patrimoine génétique paternel ainsi qu'un lot de protéines et d'ARNs de façon à initier un nouvel individu. Le succès reproductif qui recouvre les aspects de développement embryonnaire harmonieux et de santé de la descendance repose en partie sur l'intégrité de la chromatine spermatique. Les dommages à l'ADN spermatique sont clairement associés aux échecs reproductifs que ce soit en reproduction naturelle et en procréation médicalement assistée (PMA). Cette revue présente les derniers développements concernant l'organisation très particulière de la chromatine spermatique et ses impacts sur le succès reproductif quand cette organisation est perturbée, en particulier sur le développement embryonnaire et les risques trangénérationnels.

A novel antioxidant formulation designed to treat male infertility associated with oxidative stress: promising preclinical evidence from animal models.

STUDY QUESTION: Does a novel antioxidant formulation designed to restore redox balance within the male reproductive tract, reduce sperm DNA damage and increase pregnancy rates in mouse models of sperm oxidative stress? SUMMARY ANSWER: Oral administration of a novel antioxidant formulation significantly reduced sperm DNA damage in glutathione peroxidase 5 (GPX5), knockout mice and restored pregnancy rates to near-normal levels in mice subjected to scrotal heat stress. WHAT IS KNOWN ALREADY: Animal and human studies have documented the adverse effect of sperm DNA damage on fertilization rates, embryo quality, miscarriage rates and the transfer of de novo mutations to offspring. Semen samples of infertile men are known to be deficient in several key antioxidants relative to their fertile counterparts. Antioxidants alone or in combination have demonstrated limited efficacy against sperm oxidative stress and DNA damage in numerous human clinical trials, however these studies have not been definitive and an optimum combination has remained elusive. STUDY DESIGN, SIZE, DURATION: The efficacy of the antioxidant formulation was evaluated in two well-established mouse models of oxidative stress, scrotal heating and Gpx5 knockout (KO) mice, (n = 12 per experimental group), by two independent laboratories. Mice were provided the antioxidant product in their drinking water for 2-8 weeks and compared with control groups for sperm DNA damage and pregnancy rates. PARTICIPANTS/MATERIALS, SETTING, METHODS: In the Gpx5 KO model, oxidative DNA damage was monitored in spermatozoa by immunocytochemical detection of 8-hydroxy-2'-deoxyguanosine (8OHdG). In the scrotal heat stress model, male fertility was tested by partnering with three females for 5 days. The percentage of pregnant females, number of vaginal plugs, resorptions per litter, and litter size were recorded. MAIN RESULTS AND ROLE OF CHANCE: Using immunocytochemical detection of 8OHdG as a biomarker of DNA oxidation, analysis of control mice revealed that around 30% of the sperm population was positively stained. This level increased to about 60% in transgenic mice deficient in the antioxidant enzyme, GPX5. Our results indicate that an 8 week pretreatment of Gpx5 KO mice with the antioxidant formulation provided complete protection of sperm DNA against oxidative damage. In mouse models of scrotal heat stress, only 35% (19/54) of female mice became pregnant resulting in 169 fetuses with 18% fetal resorption (30/169). This is in contrast to the antioxidant pretreated group where 74% (42/57) of female mice became pregnant, resulting in 427 fetuses with 9% fetal resorption (38/427). In both animal models the protection provided by the novel antioxidant was statistically significant (P < 0.01 for the reduction of 8OHdG in the spermatozoa of Gpx5 KO mice and P < 0.05 for increase in fertility in the scrotal heat stress model). LIMITATIONS, REASONS FOR CAUTION: It was not possible to determine the exact level of antioxidant consumption for each mouse during the treatment period. WIDER IMPLICATIONS OF THE FINDINGS: Recent clinical studies confirm moderate to severe sperm DNA damage in about 60% of all men visiting IVF centers and in about 80% of men diagnosed with idiopathic male infertility. Our results, if confirmed in humans, will impact clinical fertility practice because they support the concept of using an efficacious antioxidant supplementation as a preconception therapy, in order to optimize fertilization rates, help to maintain a healthy pregnancy and limit the mutational load carried by children. STUDY FUNDING/COMPETING INTERESTS: The study was funded by the Clermont Université and the University of Madrid. P.G. is the Managing Director of CellOxess LLC, which has a commercial interest in the detection and resolution of oxidative stress. A.M. and A.P. are employees of CellOxess, LLC. J.R.D., A.G.-A. and R.J.A. are honorary members of the CellOxess advisory board.

Auditory Pathway Features Determined by DTI in Subjects with Unilateral Acoustic Neuroma.

PURPOSE: In the studies concerning the pathology of the auditory pathway in the vestibulocochlear system, few use advanced neuroimaging applications of magnetic resonance imaging (MRI) such as diffusion tensor imaging (DTI). Those who did use reported DTI changes only at the lateral lemniscus and inferior colliculus level. The aim of our study was to determine diffusion changes in the bilateral auditory pathways of subjects with unilateral acoustic neuroma (AN) and compare them with healthy controls. MATERIAL AND METHODS: A total of 15 subjects with unilateral AN along with 11 controls underwent routine MRI and DTI. Apparent diffusion coefficient (ADC) and fractional anisotropy (FA) values obtained from the lateral lemniscus, inferior colliculus, corpus geniculatum mediale, and Heschl's gyrus of the auditory pathway were then compared. RESULTS: The subjects' ADC values measured from the contralateral side were significantly higher at the lateral lemniscus, inferior colliculus, and corpus geniculatum mediale compared with those of the controls. Also, decreased FA values were noted at the inferior colliculus for both the contralateral and ipsilateral sides. The highest ADC values were detected in the inferior colliculus of the auditory pathway. CONCLUSIONS: In the auditory pathway of subjects with AN, the contralateral side is more affected than the ipsilateral side, the most affected region being the inferior colliculus. DTI is an advanced neuroimaging technique that can be used to determine the presence of microstructural damage to the auditory pathway in subjects with AN, whereas conventional MRI is not sensitive enough to detect damage.

Higher P-wave dispersion in migraine patients with higher number of attacks.

OBJECTIVE AND AIM: An imbalance of the sympathetic system may explain many of the clinical manifestations of the migraine. We aimed to evaluate P-waves as a reveal of sympathetic system function in migraine patients and healthy controls. MATERIALS AND METHODS: Thirty-five episodic type of migraine patients (complained of migraine during 5 years or more, BMI < 30 kg/m²) and 30 controls were included in our study. We measured P-wave durations (minimum, maximum, and dispersion) from 12-lead ECG recording during pain-free periods. ECGs were transferred to a personal computer via a scanner and then used for magnification of x400 by Adobe Photoshop software. RESULTS: P-wave durations were found to be similar between migraine patients and controls. Although P WD (P-wave dispersion) was similar, the mean value was higher in migraine subjects. P WD was positively correlated with P max (P < 0.01). Attacks number per month and male gender were the factors related to the P WD (P < 0.01). CONCLUSIONS: Many previous studies suggested that increased sympathetic activity may cause an increase in P WD. We found that P WD of migraine patients was higher than controls, and P WD was related to attacks number per month and male gender. Further studies are needed to explain the chronic effects of migraine.

Visual evoked potential abnormalities in migraine patients.

BACKGROUND: Visual processing in migraine has been targeted indicating that the visual pathways are involved in the migraine pathophysiology. We aimed to assess the nature of visual evoked potential (VEP) changes in migraine patients and to evaluate the role of VEP in the diagnosis of migraine. MATERIALS AND METHODS: We examined 31 female and 10 male patients with a migraine headache diagnosis according to the criteria of the International Headache Society. Control subjects had neither migraine and other types of primary headache nor familial history. VEP were elicited using a checkerboard by monocular and binocular pattern reversal stimulation. The latencies of N75, P100 and N145 and peak-to-peak amplitude of N75-P100 were measured. We compared VEP latencies and amplitudes of the monocular and binocular stimulation within each population. RESULTS: The N75 and P100 latencies were found to be significantly longer in the study group than the control group (p = 0.014 and p = 0.034, respectively) while the amplitudes in the study group were lower (p = 0.014). N145 latency was found to be longer in patients with longer duration of disease (p < 0.05). P100 latency was found to be significantly longer in patients with aura than the patients without aura (p = 0.029). N75 latency, recorded by left monocular stimulation, was elongated and the amplitude was diminished with left hemicranial headache. CONCLUSION: Measurement of VEP latency and amplitude is a valuable and reliable test for the diagnosis of migraine. Our results reflect a persisting dysfunction of precortical visual processing which might be relevant in the pathogenesis of migraine.

Breast self-examination among nurses and midwives in Odemis health district in Turkey.

BACKGROUND: The second leading cause of death due to cancer in Turkey is breast cancer, which accounts for 24% of female cancers. AIMS: To determine the practices of nurses and midwives and their attitude toward breast self-examination (BSE). SETTING AND DESIGN: The descriptive survey was conducted to determine the practices of nurses and midwives and their attitude toward BSE. It tried to cover the total population rather than sampling part of it. However, 15 nurses and midwives, where there were errors detected in their data coding papers, and who did not accept to join the study, were excluded from the study. A total of 80 nurses and midwives were included in the study group. MATERIALS AND METHODS: This survey was carried out at the State Hospital, all Public Health Cabins, and Family Health Centers, in the rural area of Izmir, a city located in the western region of Turkey. The data was collected between 15 March and 1 April 2004. STATISTICAL ANALYSIS: The analysis included descriptive statistics, to examine the association between BSE and medical history, knowledge of BSE, and attitude toward BSE. RESULTS: The results of the study indicated that 52% of the sample performed BSE. Approximately 35% of those who performed BSE reported that they acquired information regarding BSE during their work experience. A significant relationship was found between higher levels of work experience and BSE practice. Except for age, no significant relation was found between the sociodemographic factors and BSE practice. The sample showed a strong belief in the breast lump being the cause of breast cancer and it had a significant correlation with BSE practice. CONCLUSION: A positive correlation was found between nursing work experience and their practice alongside BSE medical professionals. Almost all the nurses and midwives knew how to conduct BSE, but did not prioritize practicing it.

Attempt to rescue sex-reversal by transgenic expression of the PISRT1 gene in XX PIS-/- goats.

The Polled Intersex Syndrome (PIS mutation) in goats leads to an absence of horn and to an early sex-reversal of the XX gonads. This mutation is a deletion of an 11.7-kb DNA fragment showing a tissue-specific regulatory activity. Indeed, in XX PIS(-/-) gonads the deletion of PIS leads to the transcriptional extinction of at least 3 neighboring genes, FOXL2, PFOXic and PISRT1. Among them, only FOXL2 is a 'classical' gene, encoding a highly conserved transcription factor. On the other hand, knock-out of Foxl2 in mice results in an early blocking of follicle formation without sex-reversal. This phenotype discrepancy leads to two hypotheses, either FOXL2 is responsible for XX sex-reversal in goat assuming distinct functions of its protein during ovarian differentiation in different mammals, or other PIS-regulated genes are involved. To assess the second possibility, PISRT1 expression was constitutively restored in XX PIS(-/-) gonads. Six transgenic fetuses were obtained by nuclear transfer and studied at 2 developmental stages, 41 and 46 days post-reconstruction. The gonads of these fetuses appear phenotypically identical to those of cloned non-transgenic controls. Conclusively, this result argues for FOXL2 being responsible for the PIS gonad-associated phenotype. Its invalidation in goat will help to better understand this complex syndrome.

Depression and functional outcome after stroke: the effect of antidepressant therapy on functional recovery.

AIM: The optimal strategy to prevent post-stroke depression is an important but still-unresolved issue. This study examined the differences in functional recovery among post-stroke depressed patients (DP) compared to post-stroke non-depressed patients (NDP) over the course of six months after stroke. METHODS: On the basis of a semistructured psychiatric examination, DSM-IV diagnostic criteria and the Hamilton Depression score, a consecutive series of ischemic or hemorrhagic stroke patients were included in this study. They had suffered from first-time stroke, and did not have depression diagnosis before. During follow-up, treatment with 20 mg/day citalopram per os was initiated whenever a diagnosis of depression was established. Their functional recoveries were assessed using the Scandinavian Stroke Scale, the modified Rankin scale and the Barthel index during acute hospitalization, at the time of depression diagnosis and at the third and sixth month follow-up visits. RESULTS: Forty patients met the diagnostic criteria and 11 patients suffered from depression during the follow-up period. There were no differences in demographic variables, lesion characteristics and neurological symptoms between DP and NDP. Functional recovery in DP was impaired in comparison to NDP (P<0.05). All DP, whose mood improved after administration of citalopram, and improved daily functions living functions during the follow-up. CONCLUSION: This study's findings suggest that remission of post-stroke depression is associated with improvement in functional recovery. Early diagnosis and effective treatment of depression will help the rehabilitation outcome of stroke patients.

A comparison of sural nerve conduction studies in patients with impaired oral glucose tolerance test.

OBJECTIVE: Monitoring of the sural nerve is a sensitive method for detection of neuropathies. We examined different methods of studying sural nerve conduction in a group of patients with impaired glucose tolerance (IGT) in the same study. MATERIALS AND METHODS: Several parameters of sural nerve were investigated in 20 patients. First, sensory nerve conduction studies of the sural nerve were performed on the distal-leg and the proximal-leg segments. Second, dorsal sural nerve studies were conducted. Third, the sural/radial sensory nerve action potential (SNAP) amplitude ratios were calculated. The results were compared with those obtained from 21 healthy controls. RESULTS: Abnormal results revealing peripheral neuropathy were found in only one patient and dorsal sural SNAP was absent in another patient (5%). Although the results of nerve conduction studies were within normal ranges except the patient with peripheral neuropathy, the lower extremity nerves and especially sural nerves have been found to be more affected and the parameters revealed large differences between groups (P < 0.05). Only dorsal sural nerve latency related to fasting blood glucose level in patients (<0.05). DISCUSSION AND CONCLUSIONS: Sural nerve studies should be of value to determine neuropathy in IGT patients. This study supported the idea that IGT is a transitional state before diabetes and also the importance of the dorsal sural nerve latencies for early detection of neuropathy.

Sympathetic skin responses in patients with hyperthyroidism.

BACKGROUND: The aim of this study was to investigate the disorders of sympathetic nervous system in patients with hyperthyroidism using sympathetic skin response (SSR). MATERIAL AND METHODS: Twenty-two newly diagnosed cases with hyperthyroidism were included in the study. The results were compared with those of 20 healthy controls. SSR was recorded with the contralateral electrical stimulation of the median nerve (of the upper extremities) and tibial nerve (of the lower extremities) with active electrodes placed on palms and soles and reference electrodes attached on the dorsal aspects of hands and feet. RESULTS: Ages of the cases with hyperthyroidism and controls ranged between 15-65 years (mean: 46.7 +/- 15.0 years) and 24-62 years (mean: 39.6 +/- 9.8 years) respectively (p > 0.05). In all the control subjects SSR could be obtained, while from the lower extremities of 4 cases with hyperthyroidism (18.0%) SSR could not be elicited. Mean SSR latencies of lower extremities were found significantly longer than control group (p < 0. 05). No difference was detected between mean amplitudes of SSR in upper and lower extremities. CONCLUSION: These findings suggest that SSR is useful for investigation of sympathetic nervous system involvement in cases with hyperthyroidism.

Goat PRND expression pattern suggests its involvement in early sex differentiation.

Expression of the goat prion protein gene locus was assessed by reverse transcriptase-polymerase chain reaction on testes and ovaries at various developmental stages. A weak and stochastic expression of the PRNP and PRNT genes was observed. For PRNT, it is consistent with the detected deletions of two single nucleotides within its open reading frame in ruminant genes. PRND was expressed in both tissues at all stages. Whereas its expression is constant in the ovaries, it increases in testes between 36 and 46 days postcoitum (dpc) and remains high thereafter. In testes, Doppel was found in the nucleus of germinal cells and in the cytoplasm of Leydig cells at 44 dpc. It was detected in the cytoplasm of Leydig cells and of some Sertoli and germinal cells at 62 dpc. In the ovaries, it was observed in the nucleus of germinal cells at 44 dpc and mainly in their cytoplasm at 62 dpc. This expression pattern was shown to parallel that of C-kit and suggests Doppel involvement in early testis differentiation.

Nuclear oxysterol receptors, LXRs, are involved in the maintenance of mouse caput epididymidis structure and functions.

In this study we looked at the epididymides and spermatozoa of mice knocked-out for nuclear oxysterol receptors (LXR). We have shown that LXR-deficient mice exhibited upon ageing a severe disruption of their caput epididymides associated with abnormal accumulation of neutral lipids. The epididymis defaults were correlated with sperm head fragility and infertility. In agreement with the observed caput defect in transgenic animals in which both LXRalpha and LXRbeta isoforms were disrupted, we have shown here that both receptors are expressed in caput and cauda epididymides regions. LXRbeta was predominantly expressed throughout the mouse epididymis while the expression of LXRalpha was weaker. In addition, the expression of selected genes that can be considered as markers of adult epididymis function was monitored via Northern blots in the different single and double LXR-deficient backgrounds. Altogether, the data presented here suggest that LXR receptors are important actors in epididymis function.

Ulnar nerve entrapment at wrist associated with carpal tunnel syndrome.

In this study, ulnar nerve entrapments at the wrist were investigated using nerve conduction studies in cases with established diagnosis of carpal tunnel syndrome (CTS). Cases with cervical radiculopathy and polyneuropathy as well as patients with ulnar nerve entrapment at elbow were excluded from the study. Fifty-three cases (46 females, seven males) whose ages ranged between 20 and 72 years (mean: 49.31 +/- 13.78) were evaluated. Among 53 cases, 12 (22.6%) bilateral and 41 (77.3%) unilateral CTS were detected. Totally 65 wrists evaluated and prolongation of median nerve wrist-3rd digit distal sensory latencies (DSL; N: 59; 90.7%) and wrist-abductor pollicis brevis distal motor latencies (N: 48; 73.8%) were seen. In six wrists, diagnoses were established with the detection of an increase in the differences between wrist-4th digit DSL of median and ulnar nerve. This test was used if other test results were in normal limits. Prolongation of ulnar nerve wrist-5th digit DSL were found in 12 wrists (18.4%) in cases with CTS. Among these 12 wrists mild (N: 2), moderate (N: 7) and severe (N: 3) CTS were detected. Ulnar nerve motor conduction studies provided normal results. In conclusion, we are in the opinion that for the detection of associated ulnar nerve wrist entrapments, ulnar nerve conduction studies paying special attention to DSL convey importance in established cases with CTS.

Determination of omeprazole in pharmaceuticals by derivative spectroscopy.

A new derivative UV spectroscopic method was developed for the analysis of omeprazole in borate buffer (pH 10.0; 0.1 M). Second derivative spectra were generated between 200-400 nm at N = 9, delta gamma = 31.5. The linearity range for values obtained from second derivative spectra was 0.2-40.0 micrograms ml-1. The developed method was applied to five different commercial preparations of hard gelatin capsules containing enteric coated granules. The relative standard deviations were found to be 2.24% (brand A), 1.87% (brand B), 2.80% (brand C), 4.55% (brand D) and 1.09% (brand E). The data were compared with ones obtained from the polarographic method given in the literature and no difference was found statistically.